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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
Abstract
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.
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 (http://creativecommons.org/licenses/by-nc-nd/4.0/)nMayo 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.
1,2
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.
3
These measures are imperfect, often fail to
capture the nature of physicians’work, and
leave many physicians feeling micromanaged
and demoralized.
2-4
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.”
5,6
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.
7
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
it.
3,8
National studies indicate that the prev-
alence of burnout in physicians is dramati-
cally higher than that in the general US
working population.
4,9,10
Extensive evidence
indicates professional burnout, and erosion
of meaning in work have both personal
and professional implications.
11,12
Recog-
nizing the importance of this problem, a
number of vanguard organizations and pro-
fessional societies have prioritized address-
ing this issue.
13
To date, these efforts have
typically focused on a collection of opera-
tional approaches to improve efficiency,
redesign workflows, 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.).
SPECIAL ARTICLE
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www.mayoclinicproceedings.org 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 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
as well as individual efforts to help physi-
cians strengthen personal resilience
skills.
14-20
Although these efforts may be
part of the solution, they do not address
many of the fundamental cultural issues un-
derlying this problem.
UNDERSTANDING CULTURE
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,
benefits, 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 influence 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
challenges.
21
There are at least 3 levels to
culture.
21
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 period”or “a specious
effect.”
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
22
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
assumption.
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
practices.
DIAGNOSING PROBLEMS IN THE CULTURE
OF MEDICINE AND HEALTH CARE
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
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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
reflect espoused values, it invites reflection
to identify the tacit assumption that may
actually be driving behavior.
21
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 flexibility/
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
efforts)
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
patients
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
assumptions
Professional culture Self-care is important Excessive hours, work always first,
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-
compassion
Physicians expected to be
superhuman
Belief that mistakes are the fault of
the individual and are
unacceptable
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
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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 reflection.
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.
23-26
We inculcate future
physicians with a mindset of perfectionism,
lack of vulnerability, and low self-compas-
sion.
27
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.
25,28
To
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.
29-31
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.
25
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 profession’s
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
values.
32-34
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 inefficient
and show a lack of trust.
1,35
We claim that
physicians are our most valuable resource
but saddle them with excessive, low-value,
clerical work.
2
We decry conflicts 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.
36-38
We claim to
value shared decision making and personal-
ized care for patients yet demand 20-
minute office visits that do not provide
adequate time to pursue these goals.
39
Our
mission statements espouse social justice
and fair distribution of resources for our pa-
tients and communities,
32,33,40
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 organization’s
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?
THE IMPERATIVE FOR CULTURE CHANGE
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.”
21
There
is now overwhelming evidence that this is
the situation that our profession, our organi-
zations, and the US health care delivery sys-
tem find themselves in. Symptoms of
burnout and professional distress are
dramatically more common in physicians
than in workers in other fields.
4,9,10
Burnout
has been associated with social problems
ranging from broken relationships to aban-
doning the profession.
41
Equally concerning,
there are clear associations between burnout
and mental disorders, including substance
abuse, anxiety, depression, and suicidal-
ity.
42-45
At the professional level, our lack
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of self-care, dysfunctional perfectionism,
excessive work hours, fatigue/exhaustion,
lack of vulnerability, and “physician as
hero”mentality 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
satisfaction.
11,12,46,47
Multiple studies now
report that burnout is associated with
reduced productivity, turnover, and physi-
cians leaving the profession,
41,48-50
all of
which threaten access to care precisely at a
time we are already facing substantial short-
ages of physicians.
51
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 forced“learning anxiety”dis also
created and manifests as resistance to
change.
52
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 difficult, too costly, or
too disruptive. The resulting resistance to
change often manifests as minimizing the
problem, ignoring evidence, or total denial.
21
It also takes the form of defending tradition
(“This is how we’ve always done it.”), using
anecdotes (“It worked for me.”), blaming the
individual (“You chose this profession.”),
suggesting change will be too costly (“We
don’t 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.”).
INITIATING CULTURE CHANGE
Survival anxiety and learning anxiety are
competing forces. The key to initiating
change is tipping the balance of these forces
(Figure).
21
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
A
B
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.
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is best catalyzed by decreasing learning anxi-
ety. To do so, we must find specific 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.
53
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 defined
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 define 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.
21
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-sacrifice 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)
Staffing 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 staffing 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
limitations
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 first; 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
implemented
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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 refine 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
changing.
Once we have identified the future state
to which we aspire in specific behavioral
terms, we must decrease learning anxiety
by creating psychological safety for the peo-
ple and organizations who will have to learn
new things.
21
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.
21,52
We
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 fields 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.
21
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
goal.
52,54
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.”
21
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.
21
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 define
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.
MANAGING THE TRANSITION
For a dimension of culture to change, it is
also necessary for leaders to be convinced
that a change is necessary. To manage the
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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
officer, and chief medical officer) 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
organization.
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
Defining ideal future state dCharter on Physician Well-being
53
dCharter on Professionalism for Health Care Organizations
32,33
dNational Academy of Medicine Action Collaborative on Clinician
Well-being and Resilience
13
Formal training for individuals and
organizations
dStanford Medicine Chief Wellness Officer (CWO) Training Course
dAmerican Medical Association STEPS Forward modules
dPublications delineating a road map for progress
11,16,55,56
Involvement of those who will be affected
by the changedgoal defined 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
efficiency 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,
57,58
Schwartz Center Rounds,
59
and Balint
groups
60
Practice fields, 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
55,61
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
13
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
leaders
62,63
Reward behavior and achievement of teams, not individuals
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www.mayoclinicproceedings.org 1563
change process. The first step would typically
be to “share the problem”by 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
stages.
CONCLUSION
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 benefit of our patients,
our colleagues, and our profession.
Abbreviations and Acronyms: EHR = electronic health
record
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 Ancestry.com, 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 scientific 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 (Tshana@stanford.edu).
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