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Healing the Professional Culture of Medicine


Abstract and Figures

The past decade has been a time of great change for US physicians. Many physicians feel that the care delivery system has become a barrier to providing high-quality care rather than facilitating it. Although physician distress and some of the contributing factors are now widely recognized, much of the distress physicians are experiencing is related to insidious issues affecting the cultures of our profession, our health care organizations, and the health care delivery system. Culture refers to the shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often no longer recognized. When challenges with culture arise, they almost always relate to a problem with a subcomponent of the culture even as the larger culture does many things well. In this perspective, we consider the role of culture in many of the problems facing our health care delivery system and contributing to the high prevalence of professional burnout plaguing US physicians. A framework, drawn from the field of organizational science, to address these issues and heal our professional culture is considered.
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Healing the Professional Culture of Medicine
Tait D. Shanafelt, MD; Edgar Schein, PhD; Lloyd B. Minor, MD;
Mickey Trockel, MD, PhD; Peter Schein, MBA; and Darrell Kirch, MD
The past decade has been a time of great change for US physicians. Many physicians feel that the care
delivery system has become a barrier to providing high-quality care rather than facilitating it.
Although physician distress and some of the contributing factors are now widely recognized, much of
the distress physicians are experiencing is related to insidious issues affecting the cultures of our
profession, our health care organizations, and the health care delivery system. Culture refers to the
shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often
no longer recognized. When challenges with culture arise, they almost always relate to a problem with
a subcomponent of the culture even as the larger culture does many things well. In this perspective, we
consider the role of culture in many of the problems facing our health care delivery system and
contributing to the high prevalence of professional burnout plaguing US physicians. A framework,
drawn from the eld of organizational science, to address these issues and heal our professional
culture is considered.
ª2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license ( Clin Proc. 2019;94(8):1556-1566
The past decade has been a time of
great change for US physicians. The
demand for medical care and the
complexity of the care delivered have
increased. Narrowing insurance networks
have decreased access and eroded continuity
of care. Increased physician productivity ex-
pectations have led to shorter clinic visits
and decreased time with patients. New regu-
latory requirements (meaningful use, e-pre-
scribing, and medication reconciliation)
and more widespread penetration of elec-
tronic health records (EHRs) have increased
clerical burden.
Simultaneously, an array
of metrics (eg, patient satisfaction, how
rapidly physicians process inbox messages
and close charts, quality measures, and rela-
tive value unit generation) have been intro-
duced to assess physician performance.
These measures are imperfect, often fail to
capture the nature of physicianswork, and
leave many physicians feeling micromanaged
and demoralized.
Time and motion
studies as well as analyses using EHR time
stamps indicate that 50% of the physician
workday is now spent on administrative
work and desktop medicine.
Much of
this clerical work is performed on personal
time, with studies suggesting that the
average physician spends 28 hours on clin-
ical documentation on nights and weekends
each month.
Although each of these changes had an
underlying rationale and, in many cases,
were intended to improve patient care or
manage costs, they place new burdens on
physicians. As a result, many physicians
feel the care delivery system has become a
barrier to providing high-quality care rather
than a supportive infrastructure facilitating
National studies indicate that the prev-
alence of burnout in physicians is dramati-
cally higher than that in the general US
working population.
Extensive evidence
indicates professional burnout, and erosion
of meaning in work have both personal
and professional implications.
nizing the importance of this problem, a
number of vanguard organizations and pro-
fessional societies have prioritized address-
ing this issue.
To date, these efforts have
typically focused on a collection of opera-
tional approaches to improve efciency,
redesign workows, and enhance teamwork
For editorial
comment, see
page 1401
From the Department of
Medicine (T.D.S.), Depart-
ment of Otolaryngology
(L.B.M.), Department of Psy-
chiatry and Behavioral Sci-
ences (M.T.), Stanford
University School of Medi-
cine, Stanford, CA; Organiza-
tional Culture and Leadership
Institute, Menlo Park, CA (E.S.,
P.S.); and Association of
American Medical Colleges,
Washington, DC (D.K.).
1556 Mayo Clin Proc. nAugust 2019;94(8):1556-1566 n nª2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. This is an open access article
under the CC BY-NC-ND license (
as well as individual efforts to help physi-
cians strengthen personal resilience
Although these efforts may be
part of the solution, they do not address
many of the fundamental cultural issues un-
derlying this problem.
Although physician distress and some of the
contributing factors are now widely recog-
nized, we believe that many of these prob-
lems are symptoms of more insidious
issues affecting the culture of our profession
as well as the culture of our health care orga-
nizations and the health care delivery sys-
tem. Culture refers to the shared and
fundamental beliefs, normative values, and
related social practices of a group that are
so widely accepted that they are implicit
and no longer scrutinized. In the life of indi-
viduals, organizations, and societies, culture
is a pervasive, powerful, and often unseen
force. Although visible manifestations of cul-
ture, such as workplace regulations, policies,
benets, tolerance of mistreatment or harass-
ment, professional behavior, and the incen-
tive system, are often mistaken for culture,
such characteristics are better thought of as
climate and can be altered through the ac-
tions and inuence of an individual leader
or group of leaders.
Culture is more expansive, multifaceted,
and deeply rooted in the history of the pro-
fession or organization. Culture provides
identity, order, meaning, and stability. Cul-
ture is preserved over time (passed from
older members to younger members)
because it served an adaptive purpose that
allowed a group to endure through historical
There are at least 3 levels to
Artifacts (or symbols) are the
visible manifestations of culturedour ac-
tions, behaviors, heroes, and rituals.
Espoused values are what we claim our values
and priorities to be, as manifested in mission
statements, the communications shared
across the organization or profession, pub-
licly stated values, and even advertising
and promotional messaging. Tacit assump-
tions are the underlying things we truly
believe and value, that is, the unwritten rules
that drive our daily behavior. In this context,
it should be emphasized that the term arti-
facts refers to tangible characteristics of the
culture or institution not something
belonging to an earlier periodor a specious
In the culture of medicine broadly, how
we design clinics as well as how we treat pa-
tients and colleagues are examples of arti-
facts; the Hippocratic Oath and the Charter
on Professionalism
are examples of
espoused values. The belief that physicians
should always be motivated by the best inter-
est of the patient is an example of a tacit
In addition to the overarching culture of
the profession, physicians practice within or-
ganizations that have their own cultures.
Each health care organization has its own ar-
tifacts (eg, their policies about access for the
underserved or their compensation system),
espoused values (the mission statement),
and tacit assumptions (we exist to provide
medical care to all residents in our commu-
nity regardless of the ability to pay [or
not]). A review of the mission statements
of nearly all US health care organizations in-
dicates that they claim to be committed to
providing the highest quality of care to indi-
vidual patients in need. They simultaneously
espouse different degrees of emphasis on
compassion, learning, discovery, healing hu-
manity, and strengthening communities, all
of which are noble ambitions. They differ
at the tacit assumption level in the degree
to which they emphasize other values such
as quality, community or employee health,
or economics as deep drivers of their
When challenges with culture arise, they
almost always relate to a problem with a sub-
component of the culture even as the larger
culture is well adapted to operating realities.
A simple way to diagnose problems with a
given dimension of culture is to look at in-
congruity between artifacts and espoused
values. This is often best accomplished
through group interviews and discussion
Mayo Clin Proc. nAugust 2019;94(8):1556-1566 n 1557
among members of the organization or pro-
fession along with external experts (often
consultants) who are not part of the culture.
The inclusion of experts from outside the
culture is important because insiders often
become blind to some inconsistencies and
might opt for an approach that violates
some fundamental mission assumptions
without realizing it.
When we see behavior that does not
reect espoused values, it invites reection
to identify the tacit assumption that may
actually be driving behavior.
In this frame-
work, we would propose that challenges
with the EHR, excessive clerical work, over-
emphasis on productivity (generating rela-
tive value units), loss of exibility/
autonomy, and too little time with patients
TABLE 1. Incongruence Between Artifacts and Espoused Values in Medicine
Domain Espoused value (what we say) Artifact (our behavior) What it reveals
Culture of our organizations
and health care system
Physicians are professionals (we
trust them)
Preauthorization and excessive
documentation required to
justify billing and prevent
malpractice suits
We do not trust you
Physicians are our most highly
trained and expensive workers
(we should maximize their
Excessive clerical burden and
ineffective use of time
Your time is not valuable
High-quality care is our top priority A delivery system that drives
fatigue and burnout which
erode quality of care
Economic priorities are more
important than quality
Focus on relative value units/
volume/net operating income
Commoditization of physicians and
We value patient autonomy,
shared decision making, and
tailoring care to individual needs
Visit lengths and limited staff
support preclude shared
decision making and tailoring
care to individual patient needs
Economic priorities are more
important than patient agency
We believe in social justice and fair
distribution of resources for our
patients and communities
Organizational tactics that tailor
access to optimize payer mix
and care for highly reimbursed
medical conditions rather than
patient need
Economic priorities are more
important than social justice
Professional culture Self-care is important Excessive hours, work always rst,
and often do not take care of
ourselves (diet, exercise, sleep,
and preventive health care)
Self-care is not important; short-
term productivity is more
important than sustainability
Prevention is better than treatment We do not attend to our own
health needs
Physician health is not important
To err is human A professional culture of
perfectionism, lack of
vulnerability, and low self-
Physicians expected to be
Belief that mistakes are the fault of
the individual and are
We have not yet internalized many
of the lessons of the quality
movement that errors are
inevitable in complex systems
Fatigue impairs performance Excessive work hours;
work even when ill
We do not believe this adage
applies to physicians or we are
too arrogant to admit it does
1558 Mayo Clin Proc. nAugust 2019;94(8):1556-1566 n
represent artifacts that are incongruent with
espoused values (Table 1). This incongru-
ence reveals the deeper more fundamental
tacit assumptions of our organizations,
health care delivery systems, and our profes-
sion that require reection.
We must acknowledge that at the profes-
sional level, we have some blind spots and
unhealthy norms that can lead to potentially
destructive behavior. As physicians, we tend
to overwork, imply that normal human lim-
itations do not apply to us, and often assume
the role of a hero.
We inculcate future
physicians with a mindset of perfectionism,
lack of vulnerability, and low self-compas-
We teach them that they should al-
ways defer self-care and personal
relationships as long as needed to meet pro-
fessional demands. Mistakes are the fault of
the individual and are unacceptable.
err is human, but we are superhuman. We
espouse the importance of prevention, self-
care, and personal behaviors to promote
health for our patients, but often do not
engage in these behaviors ourselves.
We prioritize professional life above all,
even if it means we are working in a manner
that is not sustainable or that renders our
medical decision making suboptimal.
One view is that these approaches served
a purpose in historical settings in which
there were too few physiciansda world in
which all physicians needed to care for as
many patients as possible and, in such situa-
tions, an exhausted physician was better
than no physician at all. Similarly, 50 years
ago, individual perfectionism by an authori-
tarian physician was our professions
approach to quality. In most settings today,
these assumptions no longer serve the best
interest of patients, physicians, or our care
delivery system.
In the cultures of our organizations and
the health care system, there is also incon-
gruence between behaviors and espoused
We claim to believe that physi-
cians are competent and trustworthy profes-
sionals who set, maintain, and enforce
professional standards but payers and regu-
lators have created a tedious process of pre-
authorization and onerous documentation
requirements that are costly and inefcient
and show a lack of trust.
We claim that
physicians are our most valuable resource
but saddle them with excessive, low-value,
clerical work.
We decry conicts of interest
with the pharmaceutical industry yet simul-
taneously promulgate compensation systems
in our health care organizations that are
designed to maximize productivity over
quality, reward overuse of resources, and
treat physicians like a unit of production
rather than a professional.
We claim to
value shared decision making and personal-
ized care for patients yet demand 20-
minute ofce visits that do not provide
adequate time to pursue these goals.
mission statements espouse social justice
and fair distribution of resources for our pa-
tients and communities,
yet we use
organizational tactics that limit access on
the basis of ability to pay.
These incongruities between stated
values and organizational behavior are clear
to physicians and create cognitive disso-
nance that breeds cynicism and a sense of
misalignment between the organizations
goals and the altruistic aims of the profes-
sion. What can we do to change some of
the tacit assumptions that are driving this
system or ameliorate their negative effects?
Cultures change when there is a stimulus
that upsets the equilibrium. Leaders and
members of a culture must believe some-
thing bad will happen if they do not change.
This precipitates survival anxiety.
is now overwhelming evidence that this is
the situation that our profession, our organi-
zations, and the US health care delivery sys-
tem nd themselves in. Symptoms of
burnout and professional distress are
dramatically more common in physicians
than in workers in other elds.
has been associated with social problems
ranging from broken relationships to aban-
doning the profession.
Equally concerning,
there are clear associations between burnout
and mental disorders, including substance
abuse, anxiety, depression, and suicidal-
At the professional level, our lack
Mayo Clin Proc. nAugust 2019;94(8):1556-1566 n 1559
of self-care, dysfunctional perfectionism,
excessive work hours, fatigue/exhaustion,
lack of vulnerability, and physician as
heromentality are not serving us well.
Survival anxiety should also be high for
all stakeholders in our health care organiza-
tions and delivery system. Physician burnout
is associated with reduced quality of care,
increased medical errors, and lower patient
Multiple studies now
report that burnout is associated with
reduced productivity, turnover, and physi-
cians leaving the profession,
all of
which threaten access to care precisely at a
time we are already facing substantial short-
ages of physicians.
The threat and the
imperative for change are not hypothetical.
There are already negative effects on patient
care, the profession, and the system in which
they interact.
Once survival anxiety occurs, an
opposing forcedlearning anxietydis also
created and manifests as resistance to
The essence of learning anxiety is
the realization that we may not be able to
make the changes needed to solve the prob-
lem. They will be too difcult, too costly, or
too disruptive. The resulting resistance to
change often manifests as minimizing the
problem, ignoring evidence, or total denial.
It also takes the form of defending tradition
(This is how weve always done it.), using
anecdotes (It worked for me.), blaming the
individual (You chose this profession.),
suggesting change will be too costly (We
dont have the resources.), trying to justify
ignoring one problem by articulating a larger
unrelated or tangentially related problem
(There are children starving in Africa.or
Many of our patients cannot even afford
to buy food.), or the belief that virtues
and vice cannot be separated (eg, If we
acknowledge human limitations, we cannot
uphold high standards.).
Survival anxiety and learning anxiety are
competing forces. The key to initiating
change is tipping the balance of these forces
Although the temptation is to do
so by further increasing survival anxiety, this
approach often just increases resistance to
change and the tension in the system.
Once the need for change is recognized, it
Steps to create psychologic safety
and reduce learning anxiety
• Involvement in the implementation
of change
• Education and formal training
• Positive role models
• Advisors and coaches
• Opportunities to practice
• Bidirectional communication
between leaders and those affected
• Supportive structures, processes,
rewards, and controls
Survival anxiety
Status quo Positive change
Learning anxiety
Factors driving survival anxiety
• Physician suicide
• Decreased quality/medical
errors due to distress
• Turnover
• Productivity issues
• Decrease patient satisfaction
• Fear we may not achieve our
organizational goals
Concerns contributing to
learning anxiety
• Can we change?
• I do not know what to do
What will I give up/lose?
• It will be too hard (will it work?)
• Fear loss of power or prestige
• Fear temporary incompetence
Survival anxiety
Status quo Positive change
Learning anxiety
FIGURE. Balance of forces. A, Survival anxiety driving change in medicine offset by learning anxiety. B, Reducing learning anxiety to tip
the balance in favor of change.
1560 Mayo Clin Proc. nAugust 2019;94(8):1556-1566 n
is best catalyzed by decreasing learning anxi-
ety. To do so, we must nd specic areas in
which change is feasible and in which the in-
dividuals who will have to change are
engaged and supported rather than forced
to change.
We begin by articulating a compelling
positive vision of what the ideal future state
would look like. The recently published
Charter on Physician Well-being is an excel-
lent framework from which to build.
Mature cultures, such as the culture of med-
icine and the culture of most health care or-
ganizations, typically must unlearn some old
habits and ways of thinking before new ones
can be incorporated. Once we have dened
the ideal future state, we can then evaluate
how it differs from the present state and
identify gaps and barriers that need to be
addressed to make progress (Table 2). This
comparison helps us dene the old beliefs
and habits we need to unlearn as well as
the new things we need to learn, thereby
allowing us to plan and manage the change.
In planning culture changes, it is critical
to recognize that many of the elements that
constitute our professional culture are a
source of strength. These positive aspects
of our culture will help us change the dimen-
sions that need changing.
The robust cul-
ture of medicine includes countless
praiseworthy elements such as altruism,
TABLE 2. Present State and Ideal Future State
Present state Ideal future state
Neglect and self-sacrice to a fault Self-care (rest and mental health)dviewed as
necessary to preserve the effectiveness of physicians
Isolation Activated support network (personal and colleagues)
Fatigue Healthy rest and sleep habits
Rarely self-calibrate Regular self-calibration
Multiple barriers (including state licensure questions)
and stigma associated with seeking help
No stigma for seeking help for mental health issues
Asking for help is a sign of weakness Accept vulnerability (ok to ask for help)
Stafng models without redundancy and without
margin for physician illness. Staff to average demand;
times of peak demand handled by the existing staff
taking on the overload to the point of exhaustion
and unsafe practices
Systems that acknowledge human limitations and
provide stafng for optimal care at peak demand,
not at average demand
No limits on work or workload. No attention to
fatigue or sleep-related impairment after complete
training. Failure to acknowledge the personal impact
of traumatic events, patient death, and unfavorable
patient outcomes on the physician
Systems that acknowledge humanity and human
Perfectionism Self-compassion
Excessive low-value clerical and bureaucratic work that
does not improve quality of care
Limited low-value clerical work
Culture of fear Culture of safety
Work always rst; no limitations on intrusion of work
into personal life
Work-life integration; group norms favoring personal
health and healthy relationships
Burnout common Burnout rare
Professional environment that often leads to erosion
of meaning, purpose, and altruism
Environment that cultivates and strengthens meaning,
purpose, and altruism
New regulations and requirements implemented
without accounting for the time or cognitive burden
associated with those requirements or adequate
input from physicians
Time and cognitive burden associated with new
regulations and requirements accounted for and
greater input from physicians in design before
Mayo Clin Proc. nAugust 2019;94(8):1556-1566 n 1561
service, dedication, compassion, and a
commitment to excellence and professional
competence. We are motivated by the needs
of our patients and what is best for them. We
are deeply committed to supporting our col-
leagues. We believe in the biomedical basis
of disease, including mental disorders, and
are fervently against stigmatizing health con-
ditions. Although we believe in being heroic
healers, we also have a foundational belief in
humility. We know some of our current ap-
proaches are wrong and we are dedicated to
objectively testing interventions and using
evidence to rene them. The distress and
burnout created by select professional norms
and certain aspects of the practice environ-
ment run counter to these deeply held
values, and it is these values that will help
us reform those aspects of our professional
and organizational cultures that require
Once we have identied the future state
to which we aspire in specic behavioral
terms, we must decrease learning anxiety
by creating psychological safety for the peo-
ple and organizations who will have to learn
new things.
We will have to identify new
collaborative strategies and tactics for physi-
cians and leaders to gain experience with
new modes of working, group dynamics,
and different organizational norms.
must provide formal training opportunities
and the time and resources to participate
for leaders, groups, and teams. We will
need positive role models (individuals,
leaders, and organizations) who help show
what the new way looks like. We will need
practice elds that allow units to try new ap-
proaches to work, along with advisors and
coaches to help them be successful. We
will need new systems, structures, controls,
rewards, and processes consistent with
desired changes.
Although the learners do
not always get to choose the goal, they
must have some control of the process of
learning and how they will achieve the
Bidirectional communication be-
tween leaders and learners throughout this
process is critical to ensure that the vision
of the future state is clear and that the con-
cerns or reservations of the learners are
understood and appreciated. Although this
inclusive approach is slower, such involve-
ment is critical to implementing and inter-
nalizing the new norms and values and
incorporating them into the existing culture.
When it comes to improving physician well-
being, all of these steps have already begun
(Table 3).
It is important to recognize that once a
culture is mature, it can only be purposefully
changed through managed evolution.
This means that some beliefs and values
have to be deliberately dropped, some new
ones adopted, and some transformed. The
hardest part of this process is to come to
terms with the present culture, which is
taken for granted. Therefore, in diagnosing
the present culture and identifying the po-
tential areas of change, it is important to
create a temporary parallel learning structure
to both design the future and assess the pre-
sent. A parallel learning structure involves a
group within the culture developing and
testing a new approach. Some member(s)
(individuals, work units, divisions/depart-
ments, or organizations) within the culture
must separate and be exposed to new ways
of thinking, allowing an objective assess-
ment of the strengths and weakness of the
current approach, as well as learning new
ways of behaving and thinking.
This may
involve scanning the environment for solu-
tions that can be adopted or trial and error
learning.New solutions in the parallel sys-
tem can then illustrate for the rest of the or-
ganization (or to other organizations) how
the new way can work and help dene
what it looks like. This decreases learning
anxiety for the rest of the group and encour-
ages those who continue to resist change to
adapt or leave. Pilot studies, phased initia-
tives, or empowering one department or
group to develop and test as an alternative
method before scaling it more broadly are
also useful structures to facilitate learning
new approaches.
For a dimension of culture to change, it is
also necessary for leaders to be convinced
that a change is necessary. To manage the
1562 Mayo Clin Proc. nAugust 2019;94(8):1556-1566 n
transition, a team consisting of top execu-
tives and representatives of the major units
of the organization plus representative stake-
holders outside the organization should be
constituted as a change steering task force.
This team must identify the problem and set
in motion the design, planning, and imple-
mentation of the next steps. The group
should become part of the basic parallel
structure and continue to exist throughout
the change program and be accountable for
the various interventions that are made.
Top level leaders (eg, dean, chief executive
ofcer, and chief medical ofcer) must
spearhead and remain deeply involved in
this work to sponsor, support, or supply
cover for the various initiatives that will arise
within the different parts and levels of the
The steering committee must understand
the dynamics of the change process and recog-
nize that all forms of the assessment of the pre-
sent culture as well as change proposals are
interventions in their own right and will have
known and unknown consequences. If major
behavioral changes or changes in beliefs and
values are envisioned, it becomes essential
for this planning group to involve the individ-
uals who will become targets of the change,
because the best way to overcome learning
anxiety and make the learners feel psycholog-
ically safe is for them to become involved in the
TABLE 3. Steps to Facilitate Culture Change Related to Physician Well-being
Key step Existing examples
Dening ideal future state dCharter on Physician Well-being
dCharter on Professionalism for Health Care Organizations
dNational Academy of Medicine Action Collaborative on Clinician
Well-being and Resilience
Formal training for individuals and
dStanford Medicine Chief Wellness Ofcer (CWO) Training Course
dAmerican Medical Association STEPS Forward modules
dPublications delineating a road map for progress
Involvement of those who will be affected
by the changedgoal dened but not the
process; not everyone (organization or
individual) will get to the goal in the
same way
Recognition of the need for a menu of choicesdthere is not a single
solution (eg, scribes are not the only approach to improve the
efciency of practice and mindfulness is not the only approach to
personal resilience)
Training of groups and teams COlleagues Meeting to Promote And Sustain Satisfaction
(COMPASS) groups,
Schwartz Center Rounds,
and Balint
Practice elds, coaches, and feedback Time, resources, and support to learn the new way
Positive role models Vanguard organizations that have appointed a CWO and established a
program on physician well-being
Efforts by leading professional societies: American Medical Association,
Association of American Medical Colleges, Accreditation Council of
Graduate Medical Education, American College of Physicians,
American Academy of Family Physicians, and others
Support groups for learning organizations American Conference on Physician Health/International Conference
on Physician Health
Stanford CWO Training Course
Physician Wellness Academic Consortium
Collaborative for Healing and Renewal in Medicine
Systems, rewards, controls, and structures
consistent with the desired changes
Training and coaching for leaders in new behaviors that cultivate
engagement; assess and reward the new behaviors desired in
Reward behavior and achievement of teams, not individuals
Mayo Clin Proc. nAugust 2019;94(8):1556-1566 n 1563
change process. The rst step would typically
be to share the problemby bringing together
leaders of the relevant groups that would be
affected by the changes to begin dialogues
around their perception of the problem and
cocreate what adaptive moves might have to
be made, how the culture might aid or hinder
the change, what parts of the culture would
have to be evolved, and especially what the sys-
temic effects would be of proposed changes.
Building relationships at this level early is
also a necessary investment in successful
implementation at the later intervention
If we are going to make substantive progress
in many of the problems facing our health
care delivery system and the high prevalence
of professional burnout plaguing US physi-
cians, we must recognize the cultural dimen-
sions to these challenges. This will require
an honest appraisal and new dialogue at
the level of our profession, our health care
organizations, and the health care delivery
system. Some may say such efforts are weak-
ening the profession. They incorrectly will
suggest that we are overstating the depth
and breadth of the cultural problem and
will focus only on artifacts rather than the
fundamental issues related to a lack of trust
in physicians and economic assertions that
view physicians as units of production.
They will suggest that attending to self-
care, acknowledging human limitations,
and cultivating self-compassion mean advo-
cating for lower standards, less commitment,
and coddling of physicians and physicians in
training. This predictable learning anxiety
and the path to overcoming it to make mean-
ingful progress are described in the system-
atic approach outlined above. It is time for
an honest look in the mirror and beginning
the important work to heal the culture of
medicine for the benet of our patients,
our colleagues, and our profession.
Abbreviations and Acronyms: EHR = electronic health
Potential Competing Interests: Dr Shanafelt is a coin-
ventor of the Physician Well-Being Index, Medical Student
Well-Being Index, Nurse Well-Being Index, and Well-
Being Index. Mayo Clinic holds the copyright for these in-
struments and has licensed them for use outside Mayo
Clinic. Dr Shanafelt receives a portion of any royalties paid
to Mayo Clinic. As an expert on the topic of the well-
being of health care providers, Dr Shanafelt often presents
ground rounds/keynote lecture presentations as well as ad-
vises health care organizations. He receives honoraria for
some of these activities. Dr E. Schein and Mr P. Schein
are cofounders of the Organizational Culture and Leader-
ship Institute and have received honorarium for teaching
in the Clinical Effectiveness Leadership Training course
work at Stanford Health Care. Dr Minor reports receiving
compensation during the past 12 months as an advisor to
General Atlantic and unvested stock options for serving
on advisory boards of, Mammoth Biosciences,
and Mission Bio. He has received payment for lectures from
Shanghai Sansi Institute Business Management Consulting,
Weill Cornell Medicine, and Vanderbilt University Medic.
He is on the scientic advisory board of Sensyne Health.
He was a senior advisor to Havencrest Healthcare Partners.
He spoke at the Imagine Solutions Conference held in
Naples, FL, and received support for travel and hotel ac-
commodation. Dr Trockel receives occasional honorarium
payments for talks given on the topic of physician wellness.
Dr Kirch reports no competing interests.
Correspondence: Address to Tait D. Shanafelt, MD, Stan-
ford University School of Medicine, 300 Pasteur Dr,
Room 3215, Stanford, CA 94305 (
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... The hidden curriculum [43] describes certain informal, often unspoken norms that make it difficult for the doctor to expose emotions, weakness, and illness or to admit mistakes in a professional medical setting. The conclusion of a paper by Tait Shanafelt and Schein that discussed several of these elements is that change is necessary to "heal the professional culture of medicine" [44]. ...
... Some researchers argue that psychological safety of employees, such as valued feed-back and openly admitting to mistakes, is not part of the organizational tradition in the field of health care [44,60]. To create psychological safety, Schein suggests several activities that can be implemented including a focused dialogue with the goal of helping participants to relax sufficiently to examine their own assumptions and to be able to consider other assumptions as equally valid or true. ...
... Several topics emphasized in peer support conversations are known drivers of burnout among doctors: lack of support, fear of voicing concerns at work, excessive workloads, work-home conflicts, negative leadership culture and a lack of comfort with their amount of responsibility at work [3,4,8,44,[61][62][63][64][65][66]. In the interviews, explicit statements were made indicating that speaking up at work entails taking a personal risk and that some of the interviewees did not know where else to turn for help with their workrelated problems. ...
Full-text available
Background Doctors’ health is of importance for the quality and development of health care and to doctors themselves. As doctors are hesitant to seek medical treatment, peer support services, with an alleged lower threshold for seeking help, is provided in many countries. Peer support services may be the first place to which doctors turn when they search for support and advice relating to their own health and private or professional well-being. This paper explores how doctors perceive the peer support service and how it can meet their needs. Materials and methods Twelve doctors were interviewed a year after attending a peer support service which is accessible to all doctors in Norway. The qualitative, semi-structured interviews took place by on-line video meetings or over the phone (due to the COVID-19 pandemic) during 2020 and were audiotaped. Analysis was data-driven, and systematic text condensation was used as strategy for the qualitative analysis. The empirical material was further interpreted with the use of theories of organizational culture by Edgar Schein. Results The doctors sought peer support due to a range of different needs including both occupational and personal challenges. They attended peer support to engage in dialogue with a fellow doctor outside of the workplace, some were in search of a combination of dialogue and mental health care. The doctors wanted peer support to have a different quality from that of a regular doctor/patient appointment. The doctors expressed they needed and got psychological safety and an open conversation in a flexible and informal setting. Some of these qualities are related to the formal structure of the service, whereas others are based on the way the service is practised. Conclusions Peer support seems to provide psychological safety through its flexible, informal, and confidential characteristics. The service thus offers doctors in need of support a valued and suitable space that is clearly distinct from a doctor/patient relationship. The doctors’ needs are met to a high extent by the peer-support service, through such conditions that the doctors experience as beneficial.
... The culture of medicine often rewards physician attitudes and behaviors that detract from wellness. 31 Physicians internalize the culture of medicine that promotes perfectionism and downplays personal vulnerability. 32 Physicians are reluctant to protect and preserve their wellness, believing selfsacrifice makes them good doctors. ...
Physician burnout is increasing, but navigating its prevention involves a complex intersection of physical, psychological, social, and organizational strategies.
... Yes 249 (31.5) [6]. Further understanding of this phenomenon is critical in creating a culture of medicine that supports selfcare, boundary setting, and a sustainable, healthy work environment [38]. In addition, the identified communication domain may have implications for understanding psychological safety, an emerging important construct in understanding and addressing group dynamics in healthcare [15,39]. ...
Full-text available
Background Measurement is one of the critical ingredients to addressing the well-being of health care professionals. However, administering an organization-wide well-being survey can be challenging due to constraints like survey fatigue, financial limitations, and other system priorities. One way to address these issues is to embed well-being items into already existing assessment tools that are administered on a regular basis, such as an employee engagement survey. The objective of this study was to assess the utility of a brief engagement survey, that included a small subset of well-being items, among health care providers working in an academic medical center. Methods In this cross-sectional study, health care providers, including physicians and advanced clinical practitioners, employed at an academic medical center completed a brief, digital engagement survey consisting of 11 quantitative items and 1 qualitative item administered by Dialogue™. The emphasis of this study was on the quantitative responses. Item responses were compared by sex and degree, domains were identified via exploratory factor analysis (EFA), and internal consistency of item responses was assessed via McDonald’s omega. Sample burnout was compared against national burnout. Results Of the 791 respondents, 158 (20.0%) were Advanced Practice Clinicians (APCs), and 633 (80.0%) were Medical Doctors (MDs). The engagement survey, with 11 items, had a high internal consistency with an omega ranging from 0.80–0.93 and was shown, via EFA, to have three domains including communication, well-being, and engagement. Significant differences for some of the 11 items, by sex and degree, in the odds of their agreement responses were found. In this study, 31.5% reported experiencing burnout, which was significantly lower than the national average of 38.2%. Conclusion Our findings indicate initial reliability, validity, and utility of a brief, digital engagement survey among health care professionals. This may be particularly useful for medical groups or health care organizations who are unable to administer their own discrete well-being survey to employees.
... Supporting network: As the health care system becomes more complex, physicians are increasingly employed by large health care organizations. 76 Physicians within these complex health care systems have a decreased sense of autonomy and control over their work. 77 Many physicians feel they are just "cogs in the wheel" at their institutions. ...
Full-text available
Surgical complications remain common in health care and constitute a significant challenge for hospitals, surgeons, and patients. While they cause significant physical, financial, and psychological harm to patients and their families, they also heavily burden the involved physicians. This phenomenon, known as the “second victim,” results in negative short and long-term physical, cognitive, and psychological consequences on the surgeon. In this review, we explored the intricate connections between the surgeons' emotional response to adverse events concerning the patient outcome, perceived peer reaction, and existing social and institutional support systems. Using a selective literature review coupled with personal experiences, we propose a model of this complex interaction and suggest specific interventions to ameliorate the severity of response within this framework. The institution of the proposed interventions may improve the psychological well-being of surgeons facing complications and promote a cultural shift to better support physicians when they occur.
Patient age, time of day, and supplement use influence screening results; repeat testing is advised. Avoid treating to improve mood, cognition, fatigue, or quality of life.
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Background: Professional fulfillment is crucial for physicians' well-being and optimal patient care. Highly demanding work environments, perfectionism and self-critical attitudes jeopardize physicians' professional fulfillment. Objective: To explore to what extent a kinder attitude towards the self, i.e. self-kindness, was associated with physicians' professional fulfillment and whether this relationship was mediated by personal resilience and work-home interference. Methods: In 2020, cardiologists (n = 374) in the Netherlands participated in a web-based survey. Self-kindness was measured by the self-kindness subscale of the Self-Compassion Scale, personal resilience by the Brief Resilience Scale, work-home interference by the negative Work-Home Interference subscale of the Survey Work-Home Interaction-Nijmegen, and professional fulfillment by the corresponding subscale of the Professional Fulfillment Index. Using Hayes' SPSS macro PROCESS v3.5, the authors tested the parallel mediation model. Results: Self-kindness was not directly associated with professional fulfillment (direct effect = .042, p = .36, 95% CI: -0.048, 0.132). Self-kindness was indirectly related to professional fulfillment through individual resilience (indirect effect = .049, 95% CI: .020, 0.086) and work-home interference (indirect effect = .057, 95% CI: .023, 096). Conclusions: This study suggests that improving physicians' self-kindness may enhance professional fulfillment through personal resilience and work-home interference. Our findings may stimulate and remind physicians to be kind towards themselves as it may benefit them and their patients.
Introduction: Multiple national studies suggest that among physicians, physiatrists are at increased risk for occupational burnout. Objective: The aim of the study is to identify characteristics of the work environment associated with professional fulfillment and burnout among US physiatrists. Design: Between May and December 2021, a mixed qualitative and quantitative approach was used to identify factors contributing to professional fulfillment and burnout in physiatrists. Setting: Online interviews, focus groups, and survey were conducted. Participants: The participants are physiatrists in the American Academy of Physical Medicine and Rehabilitation Membership Masterfile. Main outcome measures: Burnout and professional fulfillment were assessed using the Stanford Professional Fulfillment Index. Results: Individual interviews with 21 physiatrists were conducted to identify domains that contributed to professional fulfillment followed by focus groups for further definition. Based on themes identified, scales were identified or developed to evaluate: control over schedule (6 items, Cronbach α = 0.86); integration of physiatry into patient care (3 items, Cronbach α = 0.71); personal-organizational values alignment (3 items, Cronbach α = 0.90); meaningfulness of physiatrist clinical work (6 items, Cronbach α = 0.90); teamwork and collaboration (3 items, Cronbach α = 0.89). Of 5760 physiatrists contacted in the subsequent national survey, 882 (15.4%) returned surveys (median age, 52 yrs; 46.1% women). Overall, 42.6% (336 of 788) experienced burnout and 30.6% (244 of 798) had high levels of professional fulfillment. In multivariable analysis, each one-point improvement in control over schedule (odds ratio = 1.96; 95% confidence interval = 1.45-2.69), integration of physiatry into patient care (odds ratio = 1.77; 95% confidence interval = 1.32-2.38), personal-organizational values alignment (odds ratio = 1.92; 95% confidence interval = 1.48-2.52), meaningfulness of physiatrist clinical work (odds ratio = 2.79; 95% confidence interval = 1.71-4.71), and teamwork and collaboration score (odds ratio = 2.11; 95% confidence interval = 1.48-3.03) was independently associated with higher likelihood of professional fulfillment. Conclusions: Control over schedule, optimal integration of physiatry into clinical care, personal-organizational values alignment, teamwork, and meaningfulness of physiatrist clinical work are strong and independent drivers of occupational well-being in US physiatrists. Variation in these domains by practice setting and subspecialty suggests that tailored approaches are needed to promote professional fulfillment and reduce burnout among US physiatrists.
Although surgical training programs have nearly reached gender parity, pregnancy and parenthood remain challenging for female surgeons, with obstetric risks related to occupational demands, stigma, inconsistent and brief parental leaves, a paucity of postpartum support for lactation and childcare, and little mentorship on work-family integration. This work environment causes many to postpone starting a family, which leads to higher risks of infertility among female surgeons compared to their male peers. Perception of work-family incompatibility jeopardizes recruitment and retention of our surgical workforce, as it deters medical students from the profession, increases risk of resident attrition, and leads to burnout and career dissatisfaction. The challenges of parenthood for female surgeons was the focus of a Hot Topics session during the 2022 Academic Surgical Congress, the discussion of which is presented herein with recommendations for policy change to better support maternal-fetal health and the needs of surgeons with young children.
Ambiguity and uncertainty are unavoidable elements of clinical practice. Although they can cause discomfort for both clinicians and patients, they can also be used to positive effect ensuring safer clinical practice that is tailored to individuals. As paramedics generally work in areas of practice where they encounter undifferentiated complaints with limited resources to investigate, diagnostic uncertainty can prove a challenge on a regular basis. Similarly, even when paramedics are fairly confident of the diagnosis, optimal management is frequently unclear or unachievable. This article presents practical short-term strategies to manage both diagnostic and management uncertainty in clinical practice. This article also suggests longer-term tactics that can be developed individually and collectively beginning with developing capability over competence through to changing culture and providing space for supervision. While these strategies may not completely eliminate the discomfort that can arise when faced with ambiguity and uncertainty, they can enable a greater tolerance for it, improve clinical practice, and ultimately benefit patients.
This special focus issue article provides a large number of contemporary and seminal resources developed to improve well-being, and discusses specific challenges and proposed strategies to mitigate burnout through the Veterans Health Administration, a large Private Academic Practice, and Academic Medical Centers.
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Objective: To evaluate the prevalence of burnout and satisfaction with work-life integration among physicians and other US workers in 2017 compared with 2011 and 2014. Participants and methods: Between October 12, 2017, and March 15, 2018, we surveyed US physicians and a probability-based sample of the US working population using methods similar to our 2011 and 2014 studies. A secondary survey with intensive follow-up was conducted in a sample of nonresponders to evaluate response bias. Burnout and work-life integration were measured using standard tools. Results: Of 30,456 physicians who received an invitation to participate, 5197 (17.1%) completed surveys. Among the 476 physicians in the secondary survey of nonresponders, 248 (52.1%) responded. A comparison of responders in the 2 surveys revealed no significant differences in burnout scores (P=.66), suggesting that participants were representative of US physicians. When assessed using the Maslach Burnout Inventory, 43.9% (2147 of 4893) of the physicians who completed the MBI reported at least one symptom of burnout in 2017 compared with 54.4% (3680 of 6767) in 2014 (P<.001) and 45.5% (3310 of 7227) in 2011 (P=.04). Satisfaction with work-life integration was more favorable in 2017 (42.7% [2056 of 4809]) than in 2014 (40.9% [2718 of 6651]; P<.001) but less favorable than in 2011 (48.5% [3512 of 7244]; P<.001). On multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians were at increased risk for burnout (odds ratio, 1.39; 95% CI, 1.26-1.54; P<.001) and were less likely to be satisfied with work-life integration (odds ratio, 0.77; 95% CI, 0.70-0.85; P<.001) than other working US adults. Conclusion: Burnout and satisfaction with work-life integration among US physicians improved between 2014 and 2017, with burnout currently near 2011 levels. Physicians remain at increased risk for burnout relative to workers in other fields.
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Background Awareness of the economic cost of physician attrition due to burnout in academic medical centers may help motivate organizational level efforts to improve physician wellbeing and reduce turnover. Our objectives are: 1) to use a recent longitudinal data as a case example to examine the associations between physician self-reported burnout, intent to leave (ITL) and actual turnover within two years, and 2) to estimate the cost of physician turnover attributable to burnout. Methods We used de-identified data from 472 physicians who completed a quality improvement survey conducted in 2013 at two Stanford University affiliated hospitals to assess physician wellness. To maintain the confidentially of survey responders, potentially identifiable demographic variables were not used in this analysis. A third party custodian of the data compiled turnover data in 2015 using medical staff roster. We used logistic regression to adjust for potentially confounding factors. Results At baseline, 26% of physicians reported experiencing burnout and 28% reported ITL within the next 2 years. Two years later, 13% of surveyed physicians had actually left. Those who reported ITL were more than three times as likely to have left. Physicians who reported experiencing burnout were more than twice as likely to have left the institution within the two-year period (Relative Risk (RR) = 2.1; 95% CI = 1.3–3.3). After adjusting for surgical specialty, work hour categories, sleep-related impairment, anxiety, and depression in a logistic regression model, physicians who experienced burnout in 2013 had 168% higher odds (Odds Ratio = 2.68, 95% CI: 1.34–5.38) of leaving Stanford by 2015 compared to those who did not experience burnout. The estimated two-year recruitment cost incurred due to departure attributable to burnout was between $15,544,000 and $55,506,000. Risk of ITL attributable to burnout was 3.7 times risk of actual turnover attributable to burnout. Conclusions Institutions interested in the economic cost of turnover attributable to burnout can readily calculate this parameter using survey data linked to a subsequent indicator of departure from the institution. ITL data in cross-sectional studies can also be used with an adjustment factor to correct for overestimation of risk of intent to leave attributable to burnout.
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Modelling healthcare as either a product or a service neglects essential aspects of coproduction between doctors and patients. Paul Batalden shares his learning from 10 years of studying change
A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim-related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.
Importance Physician burnout has taken the form of an epidemic that may affect core domains of health care delivery, including patient safety, quality of care, and patient satisfaction. However, this evidence has not been systematically quantified. Objective To examine whether physician burnout is associated with an increased risk of patient safety incidents, suboptimal care outcomes due to low professionalism, and lower patient satisfaction. Data Sources MEDLINE, EMBASE, PsycInfo, and CINAHL databases were searched until October 22, 2017, using combinations of the key terms physicians, burnout, and patient care. Detailed standardized searches with no language restriction were undertaken. The reference lists of eligible studies and other relevant systematic reviews were hand-searched. Study Selection Quantitative observational studies. Data Extraction and Synthesis Two independent reviewers were involved. The main meta-analysis was followed by subgroup and sensitivity analyses. All analyses were performed using random-effects models. Formal tests for heterogeneity (I²) and publication bias were performed. Main Outcomes and Measures The core outcomes were the quantitative associations between burnout and patient safety, professionalism, and patient satisfaction reported as odds ratios (ORs) with their 95% CIs. Results Of the 5234 records identified, 47 studies on 42 473 physicians (25 059 [59.0%] men; median age, 38 years [range, 27-53 years]) were included in the meta-analysis. Physician burnout was associated with an increased risk of patient safety incidents (OR, 1.96; 95% CI, 1.59-2.40), poorer quality of care due to low professionalism (OR, 2.31; 95% CI, 1.87-2.85), and reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68). The heterogeneity was high and the study quality was low to moderate. The links between burnout and low professionalism were larger in residents and early-career (≤5 years post residency) physicians compared with middle- and late-career physicians (Cohen Q = 7.27; P = .003). The reporting method of patient safety incidents and professionalism (physician-reported vs system-recorded) significantly influenced the main results (Cohen Q = 8.14; P = .007). Conclusions and Relevance This meta-analysis provides evidence that physician burnout may jeopardize patient care; reversal of this risk has to be viewed as a fundamental health care policy goal across the globe. Health care organizations are encouraged to invest in efforts to improve physician wellness, particularly for early-career physicians. The methods of recording patient care quality and safety outcomes require improvements to concisely capture the outcome of burnout on the performance of health care organizations.
The current health care practice environment has resulted in a crescendo of burnout among physicians, nurses, and advanced practice providers. Burnout among health care professionals is primarily caused by organizational factors rather than problems with personal resilience. Four major drivers motivate health care leaders to build well-being programs: the moral-ethical case (caring for their people), the business case (cost of turnover and lower quality), the tragic case (a physician suicide), and the regulatory case (accreditation requirements). Ultimately, health care provider burnout harms patients. The authors discuss the purpose; scope; structure and resources; metrics of success; and a framework for action for organizational well-being programs. The purpose such a program is to oversee organizational efforts to reduce the occupational risk for burnout, cultivate professional well-being among health care professionals and, in turn, optimize the function of health care systems. The program should measure, benchmark, and longitudinally assess these domains. The successful program will develop deep expertise regarding the drivers of professional fulfillment among health care professionals; an approach to evaluate system flaws and relevant dimensions of organizational culture; and knowledge and experience with specific tactics to foster improvement. Different professional disciplines have both shared challenges and unique needs. Effective programs acknowledge and address these differences rather than ignore them. Ultimately, a professional workforce with low burnout and high professional fulfillment is vital to providing the best care to patients. Vanguard institutions have embraced this understanding and are pursuing health care provider well-being as a core organizational strategy.
Dedication to serving the interest of the patient is at the heart of medicine’s contract with society. When physicians are well, they are best able to meaningfully connect with and care for patients. However, challenges to physician well-being are widespread, with problems such as dissatisfaction, symptoms of burnout, relatively high rates of depression, and increased suicide risk affecting physicians from premedical training through their professional careers. These problems are associated with suboptimal patient care, lower patient satisfaction, decreased access to care, and increased health care costs.
Doctors are frequently affected by mental health problems, but they often present late for treatment. Alex Wessely and Clare Gerada set out an anthropological approach to why doctors make bad patients