www.thelancet.com Vol 374 November 14, 2009
Physician wellness: a missing quality indicator
Jean E Wallace, Jane B Lemaire, William A Ghali
When physicians are unwell, the performance of health-care systems can be suboptimum. Physician wellness might
not only benefi t the individual physician, it could also be vital to the delivery of high-quality health care. We review the
work stresses faced by physicians, the barriers to attending to wellness, and the consequences of unwell physicians to
the individual and to health-care systems. We show that health systems should routinely measure physician wellness,
and discuss the challenges associated with implementation.
“Healthy citizens are the greatest asset any country
Sir Winston Churchill
Physicians are important citizens of health-care systems,
and evidence indicates that many physicians are unwell.
Physicians who are aff ected by the stresses of their work
may go on to experience substance abuse, relationship
troubles, depression, or even death.1–4 Results of emerging
research show that physicians’ stress, fatigue, burnout,
depression, or general psychological distress negatively
aff ects health-care systems and patient care.5–12 Thus when
physicians are unwell, the per formance of the health-care
system can be sub optimum. The corollary is that physician
wellness might not only benefi t the individual physician,
but also be vital to the delivery of high-quality health care.5,8
We use the term wellness to capture the complex and
multifaceted nature of physicians’ physical, mental, and
emotional health and wellbeing. Much research reports
physicians’ distress or ill health in terms of burnout (when
individuals feel emotionally overwhelmed by the demands
of their job), emotional exhaustion or withdrawal, fatigue,
depression, anxiety, suicide, substance abuse, or
impairment. We also consider the positive side of being
well;5,13 Shanafelt and colleagues14 noted “Wellness goes
beyond merely the absence of distress and includes being
challenged, thriving, and achieving success in various
aspects of personal and professional life.”
programme performance from several patient-based
indicators of the quality of care received (panel 1). By
considering the relation between physician distress and
patient perceptions of care, we have the opportunity to
draw attention to physician wellness. Unfortunately, such
indicators of quality of patient care and quality within
health-care systems often seem to overlook or ignore the
issue of physician wellness. But expansion of assessments
to explicitly include physician wellness could lead to
improvements in wellness.
In this Review, we present evidence from published
reports to underscore the extent to which physicians
face stressful working conditions. We discuss how and
why physicians are unwell, and supply possible
explanations for the profession’s poor record of self-
care, a practice that is diffi cult to revoke because of
individual, pro fessional, and organisational barriers. We
review the potential consequences of self-neglect by
physicians, both individually and at the level of health-
care systems. We also address why health systems
should routinely measure physician wellness as an
indicator of health-system quality in view of the growing
recognition that suboptimum physician wellness
adversely aff ects system performance. We discuss some
of the measurement and operational challenges
associated with implementation of this missing quality
indicator, and raise several issues that will need to be
addressed to achieve the desired outcomes of improved
physician wellness and system quality.
Risk of physician ill health
Practising medicine is stressful to many physicians. For
example, authors of a Canadian study reported that 64% of
physicians feel that their workload is too heavy, and 48%
Lancet 2009; 374: 1714–21
See Editorial page 1653
Department of Sociology,
Faculty of Social Sciences
(Prof J E Wallace PhD),
Department of Medicine,
Faculty of Medicine
(Prof J B Lemaire MD,
Prof W A Ghali MD), and
Department of Community
Health Sciences, Faculty of
Medicine (Prof W A Ghali),
University of Calgary, Calgary,
Prof Jean E Wallace, Department
of Sociology, University of Calgary,
2500 University Drive NW,
Calgary, AB, Canada, T2N 1N4
Search strategy and selection criteria
We searched Medline and the Cochrane Library for review
articles (January, 1985–July, 2009) and original articles
(January, 2004–July, 2009) using several search terms to
capture: physician demographics (eg, internship and
residency, health personnel, medical staff , women physicians,
medical students, general practitioners, internist, pediatrician,
surgeon); wellness indicators (eg, burnout, suicide, fatigue,
impaired or psychological distress, stress or wellbeing, work
hours, work shifts, workload, anxiety, cognition, depression);
negative medical consequences of physician impairment (eg,
professional or diagnostic errors, fatigue, medical errors, sick
leave, sleep deprivation, work schedule tolerance); and
health-care organisational perspectives on physician wellness
(eg, occupational health, personnel staffi ng and scheduling,
personnel turnover). We focused on reports published in the
past 5 years, but did not exclude frequently referenced and
highly regarded reports published more than 5 years ago. We
also searched reference lists of reports identifi ed by this search
strategy and selected those we judged relevant. Our reference
list was modifi ed on the basis of comments from peer
reviewers. We identifi ed an extensive number of studies,
many of which could not be meaningfully acknowledged in
this report; our report is not intended to cover all present
knowledge of physician wellness. Therefore, we strategically
selected a subset of high-quality studies that we judged to be
most eff ective and relevant to draw attention to and support
the central themes of this report.
www.thelancet.com Vol 374 November 14, 2009 1715
have had an increase in their workload in the past year.16
Additionally, surveys consistently document that doctors
work many hours, averaging 50–60 h per week when not
on call.17 When physicians frequently work shifts longer
than 24 h, the resulting fatigue is associated with negative
consequences for physicians, both personally and
professionally. Personally, they have increased risk of
burnout,7 percutaneous needle stick injuries,18 and motor-
vehicle crashes or near-miss incidents when driving
home.19 Professionally, physicians have signifi cantly more
failures of attention than do those working shifts shorter
than 16 h,11 and make more serious medical errors than do
those working shifts shorter than 24 h.10
Beyond the eff ects of workload and fatigue, physicians
might be aff ected by other stressors specifi c to medicine.
For example, physicians work in emotionally-charged
situations, associated with suff ering, fear, failures, and
death, which often culminate in diffi cult interactions
with patients, families, and other medical personnel.20,21
Furthermore, excessive cognitive demands caused by
the need for quick processing of overwhelming amounts
of information for long periods can negatively aff ect
Moreover, rapid and recent changes to the practice of
medicine—eg, increased patient-care demands, remun-
era tion issues, growing bureaucracy associated with
medical practice, increased accountability, and confl ict
between the needs of the organisation and patients—are
all potential threats to physician well ness.21,23–26 In view
of these organisational shifts, much research has
focused on the substantial decline in physicians’
autonomy because of increased managerial and cost
control by governments, employers, and patients.24,27,28
For example, quality-of-care interventions attempting to
standardise care protocols are proven to provide
improved care based on evidence,29–31 but physicians who
encounter these organ isational restrictions on their
decision making and autonomy often report increased
job dissatisfaction and stress.32–35 Similarly, the rise of
managed care in countries such as the USA and Israel
has raised concerns because physicians fear that such
care will be of lower quality for patients, and reduce
physicians’ income and autonomy.28,35,36
Excessive workloads, chronic work-related stress, and
restricted autonomy lead to high occurrence of physician
stress and burnout. 46% of physicians surveyed in one
study reported medical practice to be very or extremely
stressful.37 Cohen and Patten38 recorded that 17% of
resident doctors rated their mental health as fair or poor,
which is more than double the amount reported in the
general population. Burnout seems to be common in
physicians, aff ecting an estimated 25–60%,26,39–41 and up
to 75% in some studies.7,9
The consequences of long periods of excessive work
stress and burnout could have serious outcomes for the
wellness of individual physicians (eg, substance abuse,
relationship troubles, depression, or even death).1–4,42,43
However, prevalence statistics
physicians’ mental and emotional health vary
substantially because such wellness indicators are
diffi cult to quantify and estimate. Some studies clearly
document that physicians have greater job stress and
emotional distress than do the general population.38,44–46
Other studies report that physicians have similar
wellness to the general population,3,5,47 but that
depression is heightened in female physicians, medical
students, and residents.9,42,44,48 Suicide rates for physicians
are estimated to be six times higher than in the general
population, their cardiovascular mortality is higher
than average, and about 8–12% of all practising
physicians are expected to develop a substance-abuse
disorder at some point in their career.20,49,50 Irrespective
of whether physician distress is similar to that of the
general population, or if most doctors are happy,51
recognition of the potentially harmful eff ects of stressful
work on physician wellness is important.
Suboptimum attention to self-wellness by
Physician wellness is complex and multifaceted:
individual, professional, and organisational factors might
aff ect a physician’s ability to be well. In terms of individual
factors, research suggests that physicians are not very
good at tending to many of their wellness needs or
seeking help from others.20,52–55 Arnetz20 refers to the
“ignorance, indiff erence and carelessness of physicians
towards their own health”; physicians neglect to have
physical examinations and procrastinate when seeking
medical treatment. This pattern of behaviour seems to be
universal. For example, of 18% of Canadian physicians
who were identifi ed as depressed, only 25% considered
getting help and only 2% actually did.16 Many physicians
do not have family doctors. For example, Pullen and
colleagues53 reported that only 42% of Australian
physicians studied had a general practitioner, and most
had self-prescribed drugs. Uallachain56 recorded that 30%
of young Irish physicians had not been to a general
practitioner in the previous 5 years, 65% felt unable to
take time off from work when they were ill, 92% had self-
prescribed drugs at least once, and 49% felt that they
neglected their own health. Similarly, Thompson and
colleagues55 reported that most British doctors are aware
Panel 1: Patient-based indicators for quality of care
According to the US Institute of Medicine, such indicators
include health-care processes (eg, periodic blood and urine
tests for patients with diabetes), patient outcomes (eg,
60-day survival rate of patients receiving cardiac bypass),
patient perceptions of care (eg, experience with
patient–provider communication), and the ability to provide
high-quality care associated with organisational structure
and systems (eg, entry systems for drug ordering).15
www.thelancet.com Vol 374 November 14, 2009
that they are not very good at taking care of themselves;
most said that they work when unwell and they also
expect their colleagues to do so, even though they would
not place the same expectations on their patients.
Moreover, doctors often rely on denial and avoidance as
coping strategies, which are not very eff ective;49,52 the
problem is exacerbated by the medical profession’s poor
record for giving mutual support and feedback.57 The
conspiracy of silence deters doctors from talking about
their colleagues’ distress or their concerns for their own
personal health.20 Furthermore, a perceived stigma is
associated with seeking help. Doctors might feel
uncomfortable in the role of patient, and fear that others
will interpret their need for help as an indicator of their
inability to cope.55,56 Findings show, however, that
physicians who receive support from their colleagues or
spouse are more successful in achieving wellness.58
Other predictors of physician wellness at the individual
level include physicians’ personality traits and gender.
Certain prevalent physician personality traits (eg,
perfectionism, workaholism, and type A personalities)
are associated with adverse health outcomes, including
burnout, depression, anxiety, eating disorders, and
cardiovascular disease.59 McManus and colleagues60
showed that physicians’ personalities and learning styles
are associated with their stress, burnout, and attitudes to
work. Furthermore, female physicians often face greater
challenges than do male physicians with respect to
balancing work and family responsibilities, resulting in
increased work–family confl ict and stress.61
The eff ect of professional factors on wellness is
exacerbated by the historical tendency of the profession
to ignore indicators of distress.49 Many doctors face the
ethical dilemma of choosing to protect the privacy of
their impaired colleagues or patients’ safety. Farber and
colleagues62 presented hypothetical scenarios to doctors
and showed that most doctors are more likely to report a
physician with a substance-abuse disorder than one who
is emotionally or cognitively impaired. Roberts and
colleagues63 noted that preserving confi dentiality between
colleagues is a dominant factor, even when hypothetical
doctors are at risk of suicide or patient care is
compromised. They proposed that a contributing factor
could be the present approach to educating physicians,
which rewards individual achievement, self-reliance,
independent judgment, industry, and self-sacrifi ce;
unintentionally, this approach could “inculcate the
notions that the best doctors have few needs, make no
mistakes and are never ill”.63
Physicians could also be deterred from seeking help for
physical, mental health, or substance-abuse problems
because many licensing boards discriminate against
these physicians, even if they have received eff ective
treatment and the diagnosis has no eff ect on their
professional skills and abilities.50,64,65 Many medical
licensing applications include questions that ask about
the physical health, mental health, and substance use of
applicants.64 Some licensing boards undertake investi-
gations if physicians seek treatment, which can lead to
sanctions irrespective of whether there is any evidence of
impaired functioning.66 The idea that physicians fear
damaging their careers or putting their medical licence
in jeopardy if they seek treatment for such problems is
gradually receiving increased attention by published
reports, and underscores an important consequence of
stigmatism with respect to physician ill health.67
The culture of the medical profession has been
recognised as a key factor that might deter doctors from
taking care of themselves. In a study of physicians’
attitudes towards their own health, Thompson and
colleagues55 identifi ed that general practitioners feel
pressure from both their patients and colleagues to appear
physically well, even when they are sick, because they
believe their health is interpreted as an indicator of their
medical competence. Similarly, McKevitt and colleagues68
reported that more than 80% of the general practitioners
and hospital doctors in their study worked through their
illness. Their results from interviews with doctors showed
that professional and organisational barriers, which
reinforce one another, could contribute to reluctance to
take sick leave or discuss health concerns with colleagues.68
Moreover, Baldwin and colleagues69 have shown that
trainee doctors are adopting the same behaviour that has
been previously reported in older, more established
doctors. When questioned about their response to
hypothetical illnesses, 61% of junior doctors would go to
work and wait and see if they were vomiting all night, 83%
if they had blood in their urine, 76% if they had a suspected
stomach ulcer, and 73% if they had severe anxiety.69
Health-care organisations might also falter in
provision of even basic resources for physician wellness
and self-care, such as adequate rest, recovery, and
nutrition.70 Despite these shortcomings, certain aspects
of physician wellness are being addressed by health-care
systems and professional medical organisations. Many
countries, including Canada, Australia, and the UK, are
developing programmes to identify and treat impaired
or disruptive physicians, and some health-care
organisations are targeting prevention and promoting
wellness (panel 2). These are worthy beginnings.
However, at present there are no standards to dictate
how to promote physician wellness, enforce these
mandates, or measure success.
Unwell physicians negatively aff ect health-care
Growing evidence points to important negative
consequences of physician ill health to health-care
systems by aff ecting recruitment and retention of
physicians, workplace productivity and effi ciency, and
quality of patient care and patient safety. The worldwide
shortage of physicians in primary health care makes
physician wellness especially important for recruitment
and retention to the medical profession.74,75 Medical
www.thelancet.com Vol 374 November 14, 2009 1717
school training is extremely stressful and often has
negative eff ects on students’ mental health,48,76 which
could deter individuals from entering the profession,
completing their medical training, or entering certain
medical specialties. According to fi ndings from Cohen
and Patten’s38 study, 22% of physician residents beginning
their careers as doctors would not pursue medicine if
given the opportunity to relive their career. Young
physicians report nearly twice the occurrence of burnout
compared with their older colleagues, and burnout could
begin as early as residency training.7 Although physician
shortages can be partly off set by increased reliance on
international medical graduates, immigrant doctors are
likely to face additional stressors and strains above and
beyond those that they share with their local colleagues.
Excessive job stress, burnout, and dissatisfaction are
closely related to job and career turnover.8,77,78 Physicians
who are highly dissatisfi ed with their work have increased
probability of changing jobs within medicine or leaving
medicine entirely. From a survey of University of Ottawa
physicians, 50% thought about leaving academic
medicine every week and 30% thought of leaving
medicine altogether.16 Such professional malaise impedes
recruitment of the best and the brightest individuals into
medicine and to some medical specialties.79–81 Moreover,
as workloads and stress increase, we expect turnover
rates to rise and contribute to the increasing costs
associated with recruitment and retention of physicians.
The cost of replacing a physician is estimated to be
US$150 000–300 000, dependent on the time taken to
search for, screen, and interview candidates, and revenue
lost to the health centre (eg, retaining a locum to replace
the departing physician).82 This estimate does not include
additional expenses of signing bonuses, moving
expenses, or promotion costs.
At the organisational level, physician burnout is asso-
ciated with reduced workplace productivity and effi ciency.
Such an eff ect is related to increased absenteeism, job
turnover, interest in early retirement, and probability of
ordering unnecessary tests or procedures, and reduced
practice revenue and time with patients.83 Physicians
with mental health problems are costly to organisations
because of sickness absences, suspensions, and early
Perhaps of even greater concern is the direct eff ect of
physician wellness on quality of care and patient safety.5–8,84
Firth-Cozens and Greenhalgh,6 examined physicians’
perceptions of the link between work-related stress and
patient care. 57% of participants believed that tiredness,
exhaustion, or sleep deprivation negatively aff ected patient
care, and another 28% believed that pressures from being
overworked were negatively related. Work-related stress
led to 50% reporting reduced standards of patient care (eg,
taking short cuts, not following procedures), 40% reporting
irritability or anger, 7% reporting serious mistakes not
leading to patient death, and 2·4% reporting incidents in
which the patient died. Tiredness and overwork were most
often judged to be responsible for these outcomes,
especially the most serious ones. Di Matteo and colleagues85
undertook a 2-year longitudinal study of 196 physicians to
assess the eff ect of practice characteristics, practice styles,
and job satisfaction on more than 20 000 patients with
diabetes, hypertension, and heart disease. Physicians’
overall job satisfaction had a positive eff ect on patients’
adherence to treatment and actions in managing their
chronic diseases. Williams and Skinner’s8 narrative review
of outcomes of physician job dissatisfaction support these
results: more dissatisfi ed physicians tend to have riskier
prescribing profi les, less adherent patients, and less
satisfi ed patients, all of which might indicate reduced
quality of patient care.
Findings from several studies of residents clearly show
the link between physician distress, in terms of burnout
and depression, and the eff ect on patient care, especially
medical errors. Shanafelt and colleagues7 reported that
more than 75% of their study participants met the criteria
for burnout, and these residents had two to three times
increased probability of reporting that they had provided
suboptimum patient care at least monthly or weekly. Some
of the suboptimum practices included: failure to fully
discuss treatment options or answer patient questions,
treatment or medication errors that were not due to lack of
knowledge or inexperience, and reduced attentiveness or
caring behaviour towards their patients. Similarly,
Fahrenkopf and colleagues9 recorded that 20% of residents
Panel 2: Programmes run by health-care organisations to
improve physician wellness
In the UK, the National Clinical Assessment Service aims to
“help to clarify the performance concerns [of doctors],
understand what is leading to them and support their
resolution in order to, where possible, restore safe and valued
practice”.71 The organisation off ers online resource materials
such as access to the Practitioner Health Programme that
provides a free confi dential service for doctors who have
mental or physical health concerns or addictions.
The Canadian Medical Association has a dedicated centre for
physician health and wellbeing, and every provincial medical
association within Canada has a physician wellness portfolio.
In addition to providing support to distressed physicians and
their families, the Alberta Medical Association Physician and
Family Support Program is engaged in several wellness
educational activities, such as promotion of adequate sleep
and workplace nutrition, and support for dealing with
adverse events, complaints, and medical legal litigation.
In the USA, the Joint Commission accreditation for hospitals
mandates that the medical staff “implement a process to
identify and manage matters of individual health for licensed
independent practitioners which is separate from actions
taken for disciplinary purposes“.72 The organisation also off ers
educational materials for dealing with issues such as the
disruptive health professional.73
www.thelancet.com Vol 374 November 14, 2009
studied were depressed and 75% were burned out, and
those who were burned out or depressed, or both, had
signifi cantly increased risk of making medication errors.
From a prospective longitudinal study, West and
colleagues’12 identifi ed that residents’ self-perceived
medical errors were signifi cantly and adversely associated
with overall quality of life, burnout, and the likelihood of
screening positive for depression.
Factors such as overwork, inadequate sleep, and
exhaustion, compounded with feelings of guilt, often result
in poor care that could contribute to a cycle of stress and
diminishing quality of patient care.41,52,86 Sleep deprivation
can be more incapacitating than a high blood-alcohol
concentration,87 and call-associated fatigue is related to
increased error rates in the cognitive skill domain for
surgeons.88 Halbesleben and Rathert’s89 fi ndings showed
that the depersonalisation dimension of physician burnout
was associated with decreased patient satisfaction and
lengthened recovery time after discharge. Furthermore,
research fi ndings suggest that medical students and
physicians who have a poor personal health profi le are less
likely than are those who are healthy to recommend any
kind of evidence-based screening to their patients90 or
counselling for healthy lifestyle such as moderate alcohol
use.91 In turn, physician wellness and satisfaction are
important contributors to patients’ adherence to treatment
Physician wellness as an indicator of
In view of the eff ect of suboptimum physician wellness on
health systems, measurement of provider wellness as a
health-system quality indicator could be highly benefi cial.
For eff ective improvement in health-system quality and
performance, however, quality indicators need to be both
measurable and actionable.15 We need valid and reliable
methods to measure provider wellness as an indicator of
health -system quality, and evidence about how best to inter-
vene if suboptimum system performance is identifi ed.
Fortunately, physician wellness is measurable. Despite
methodological challenges, existing instruments can
assess physician wellness at a system level. For example,
Arnetz93 used a standardised questionnaire—the quality
of work competence survey—to assess ten core
components of organisational and staff wellbeing that
included mental energy, work climate, work tempo, work-
related exhaustion, skills development, organ isational
effi cacy, and leadership. From these components, he
computed an overall weighted score that represented a
global, composite measure of the overall health of the
organisation. Arnetz94 suggests that subjective indicators
from employees can be used to gauge and improve
organisational performance and wellness. He argues that
improvement of physician wellness can improve the
organisation’s wellbeing and health, and that physician
Workplace and profession
Improved patient care
and system outcomes
Health-care system outcomes
• Recruitment and retention issues
• Lowered productivity and efficiency
• Suboptimum quality of patient care
• Reduced patient adherence and satisfaction
• Increased risk of medical errors
• Confidentiality issues
• Licensing board responses
• Culture of medicine supporting neglect of
self-care and indifference to personal wellness
• Health-care organisations’ failure to
provide basic resources for physician
• Work hours
• Emotional interactions
• Cognitive demands
• Restricted autonomy
• Structural and organisational
changes to practice
• Feelings of stress
• Substance abuse
• Risk of suicide
• Indifference to personal wellness
• Neglect of self-care
• Coping by denial and avoidance
• Conspiracy of silence
• Predisposing personality traits
Figure: A model of physician ill health and the links with health-care system outcomes, and potential interventions to improve physician and system outcomes
Solid lines are empirically supported; broken lines are potential links.
www.thelancet.com Vol 374 November 14, 2009 1719
wellness should receive the same priority as patient care
and fi nancial viability. That is, individual physician
wellness is a valid indicator for organisational health.
Measures of physician wellness also seem to be
actionable: in situations of suboptimum physician
wellness, eff ective interventions have been imple-
mented.95–98 In a study by Dunn and colleagues,95 three
interventions were introduced to a primary care group
consisting of six sites and 32 physicians. The interventions
were designed to enhance physicians’ control over their
work environment, improve effi ciency in offi ce design
and quality of staff , and contribute to a sense of satisfaction
and meaning derived from patient care. The results
showed clinically and statistically signifi cant decreases in
emotional and work-related exhaustion—key indicators of
burnout—during the study, and other improvements in
physician wellbeing were noted. In a study of stressed
physicians to assess the eff ect of a counselling intervention
on burnout, Rø and colleagues99 showed clinically and
statistically signifi cant reductions in emotional exhaustion
and sick leave at 1-year follow-up in the 185 physicians
who completed the study.
Although interventions could improve physician
wellness, very little research has directly examined the
eff ect of such interventions on patient care or health-
system performance. Although much is known about
physician distress and the negative eff ect on patient care,
little is known about whether interventions directed at
physician wellness will also improve patient care.25
However, Jones and colleagues’100 study did suggest that
stress management interventions could be benefi cial to
both physicians and their patients. They showed a strong
relation between a stressful workplace and malpractice
risk in both medical departments and hospitals.
Furthermore, they recorded signifi cant reductions in
medication errors and malpractice claims after
introduction of stress-management programmes to
22 hospitals; by contrast, rates for the 22 hospitals in the
control group (matched on bed numbers, frequency of
claims, and rural vs urban) remained unchanged.
Nevertheless, further research is needed to explore how
interventions designed to improve physician wellness are
also benefi cial to patients and the organisations that
support such interventions. Studies that identify both
individual and organisational wellness interventions, and
that assess the eff ects of such interventions on patient
care, effi ciency, and productivity, will be important to
support both the promotion of wellness programmes and
the inclusion of physician wellness as a quality indicator.
The fi gure proposes a model to show the empirically
established links between physician ill health described
in our Review, and the potential interventions that could
improve physician and system outcomes.
The fi rst step to incorporation of physician wellness as a
quality indicator is to promote dialogue among key
stakeholders (physician groups, health-system decision
makers, payers, and the general public) about the
components needed in such a quality-indicator system
to best measure physician and organisational wellness,
and the interventions needed to improve physician and
organisational wellness. Assessment of physician
wellness as an indicator of an organisation’s quality of
health care is only the fi rst step. Increased awareness of
the importance of physician wellness, both individually
and organisationally, is needed by physicians, their
patients, and their employers. A shift in the culture of
care and wellness of physicians is necessary. If these
groups do not recognise the crucial importance of
physician wellness, there is little reason to expect that
physicians and their employers will invest in taking
better care of physicians, or that the public will support
and appreciate such eff orts.
Ultimately, individual physicians will personally
benefi t from taking better care of themselves. Such
eff orts would probably lead to increased job satisfaction
and overall wellbeing, and reduced likelihood of
physicians experiencing an overwhelming sense of
stress and burnout. The organisations employing
physicians will benefi t by having more productive and
effi cient health-care providers in conjunction with
reduced absenteeism, job turnover, and recruitment and
retention issues. And perhaps the patients themselves
will benefi t by receiving better quality of care.
JEW was mainly responsible for the search of published work. All
authors contributed equally to writing of the report.
Confl icts of interest
We declare that we have no confl icts of interest.
JEW was supported by a Killam Resident Fellowship at the University
of Calgary during writing of this report. WAG is supported by a Canada
Research Chair in Health Services Research and by a Senior Health
Scholar Award from the Alberta Heritage Foundation for Medical
Research. We thank John Conly, Chair of the Department of Medicine,
University of Calgary, for his vision and support of physician wellness
research through the creation of JBL’s departmental appointment of
Vice-Chair in this domain, and JEW’s adjunct position in the
Department of Medicine. We also thank research librarian
Diane Lorenzetti for her expert assistance, and Garielle Brown and
Michael DeSouza for their help in preparation of the report.
1 Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and
coping among orthopaedic surgery residents and faculty.
J Bone Joint Surg Am 2004; 86: 1579–86.
2 Firth-Cozens J. Individual and organizational predictors of
depression in general practitioners. Br J Gen Pract 1998; 48: 1647–51.
3 Frank E, Dingle AD. Self-reported depression and suicide attempts
among U.S. women physicians. Am J Psychiatry 1999;
4 Graham J, Albery IP, Ramirez AJ, Richards MA. How hospital
consultants cope with stress at work: implications for their mental
health. Stress Health 2001; 17: 85–89.
5 Shanafelt TD, West C, Zhao X, et al. Relationship between
increased personal well-being and enhanced empathy among
internal medicine residents. J Gen Intern Med 2005; 20: 559–64.
6 Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links
between stress and lowered clinical care. Soc Sci Med 1997;
www.thelancet.com Vol 374 November 14, 2009
7 Shanafelt TD, Bradley KA, Wipf JW, Back AL. Burnout and self-
reported patient care in an internal medicine residency program.
Ann Intern Med 2002; 136: 358–67.
Williams ES, Skinner AC. Outcomes of physician job satisfaction:
a narrative review, implications and directions for future research.
Health Care Manage Rev 2003; 28: 119–40.
Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication
errors among depressed and burnt out residents: prospective cohort
study. BMJ 2008; 336: 488–91.
10 Landrigan CP, Rothschild JM, Cronin JW, et al. Eff ect of reducing
interns’ work hours on serious medical errors in intensive care
units. N Engl J Med 2004; 351: 1838–48.
11 Lockley SW, Cronin JW, Evans EE, et al, for the Harvard Work
Hours, Health and Safety Group. Eff ect of reducing interns’ weekly
work hours on sleep and attentional failures. N Engl J Med 2004;
12 West CP, Huschka MM, Novotny PJ, et al. Association of perceived
medical errors with resident distress and empathy: a prospective
longitudinal study. JAMA 2006; 296: 1071–78.
13 Weiner EL, Swain GR, Wolf B, Gottlieb M, Spickard A. A qualitative
study of physicians’ own wellness-promotion practices. West J Med
2001; 174: 19–23.
14 Shanafelt TD, Sloan JA, Haberman TM. The well being of
physicians. Am Med J 2003; 114: 513–17.
15 Committee on Redesigning Health Insurance Performance
Measures, Payment, and Performance Improvement Programs,
Institute of Medicine of the National Academies. Pathways to
quality health care. Performance measurement: accelerating
improvement. Washington, DC: National Academies Press, 2006.
16 Canadian Medical Association. Guide to physician health and well
being: facts, advice and resources for Canadian doctors. Ottawa,
ON: Canadian Medical Association, 2003.
17 Williams ES, Rondeau KV, Xiao Q, Francescutti LH. Heavy
physician workloads: impact on physician attitudes and outcomes.
Health Serv Manage Res 2007; 20: 261–69.
18 Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the
risk of self-reported percutaneous injuries in interns. JAMA 2006;
19 Barger LK, Cade BE, Ayas NT, et al, for the Harvard Work Hours,
Health, and Safety Group. Extended work shifts and the risk of motor
vehicle crashes among interns. N Engl J Med 2005; 352: 125–34.
20 Arnetz BB. Psychosocial challenges facing physicians of today.
Soc Sci Med 2001; 52: 203–13.
21 McMurray JE, Williams E, Schwartz MD, et al. Physician job
satisfaction: developing a model using qualitative data.
J Gen Intern Med 1997; 12: 711–14.
22 Levin S, Aronsky D, Hemphill R, Han J, Slagle J, France D.
Shifting toward balance: measuring the distribution of workload
among emergency physician teams. Ann Emerg Med 2007;
23 Umehara K, Yukihiro O, Kawakami N, Tsutsumi A, Fujimura M.
Association of work-related factors with psychosocial job stressors
and psychosomatic symptoms among Japanese pediatricians.
J Occup Health 2007; 49: 467–81.
24 Dunstone DC, Reames HR. Physician satisfaction revisited.
Soc Sci Med 2001; 52: 825–37.
25 Shanafelt TD, Novotny P, Johnson ME, et al. The well being and
personal wellness promotion strategies of medical oncologists in the
North Central Cancer Treatment Group. Oncology 2005; 86: 23–32.
26 Goehring C, Bouvier Gallacchi M, Kunzi B, Bovier P. Psychosocial
and professional characteristics of burnout in Swiss primary care
practitioners: a cross-sectional survey. Swiss Med Wkly 2005;
27 Landon BE, Reschovsky J, Blumenthal D. Changes in career
satisfaction among primary care and specialist physicians,
1997–2001. JAMA 2003; 289: 442–49.
28 Gross R, Tabenkin H, Brammli-Greenberg S. Factors aff ecting
primary care physicians’ perceptions of health system reform in
Israel: professional autonomy versus organizational affi liation.
Soc Sci Med 2007; 64: 1450–62.
29 Franke CA, Dickerson LM, Carek PJ. Improving anticoagulation
therapy using point-of-care testing and a standardized protocol.
Ann Fam Med 2008; 6: S28–32.
30 O’Connor C, Adhikari NK, DeCaire K, Friedrich JO. Medical
admission order sets to improve deep vein thrombosis prophylaxis
rates and other outcomes. J Hosp Med 2009; 4: 81–89.
31 Ozdas A, Speroff T, Waitman LR, Ozbolt J, Butler J, Miller RA.
Integrating “best of care” protocols into clinicians’ workfl ow via care
provider order entry: impact on quality-of-care indicators for acute
myocardial infarction. J Am Med Inform Assoc 2006; 13: 188–96.
32 Duff y RD, Richard GV. Physician job satisfaction across six major
specialties. J Vocat Behav 2006; 68: 548–59.
33 Hoff T, Whitcomb WF, Nelson JR. Thriving and surviving in a new
medical career: the case of the hospitalist physicians.
J Health Soc Behav 2002; 43: 72–91.
34 Sundquist J, Johansson SE. High demand, low control, and impaired
general health: working conditions in a sample of Swedish general
practitioners. Scand J Public Health 2008; 28: 123–31.
35 Warren MG, Weitz R, Kulis S. Physician satisfaction in a changing
health care environment: the impact of challenges to professional
autonomy, authority, and dominance. J Health Soc Behav 1998;
36 Hoff TJ. The physician as worker: what it means and why now?
Health Care Manag Rev 2001; 34: 53–70.
37 Henry J. OMA membership survey results confi rm overwhelming
level of frustration among Ontario physicians. Ont Med Rev 2004;
38 Cohen JS, Patten S. Well being in residency training: a survey
examining resident physician satisfaction both within and outside of
residency training and mental health in Alberta. BMC Med Educ
2005; 5: 21.
39 Panagopoulou EA, Montgomery A, Benos A. Burnout in internal
medicine physicians: diff erences between residents and specialists.
Eur J Intern Med 2006; 17: 195–200.
40 Renzi C, Tabolli S, Ianni A, Di Petro C, Puddu P. Burnout and job
satisfaction comparing healthcare staff of a dermatological hospital
and a general hospital. J Eur Acad Dermatol Venereol 2005; 19: 153–57.
41 Goitein L, Shanafelt TD, Wipf JE, Slatore CG, Back AL. The eff ects of
work-hour limitations on resident well being, patient care, and
education in an internal medicine residency program.
Arch Intern Med 2005; 165: 2601–06.
42 Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal
ideation among U.S. medical students. Ann Intern Med 2008;
43 Van Der Heijden F, Dillingh G, Bakker A, Prins J. Suicidal thoughts
among medical residents with burnout. Arch Suicide Res 2008;
44 Hsu K, Marshall V. Prevalence of depression and distress in a large
sample of Canadian residents, interns, and fellows. Am J Psychiatry
1987; 144: 1561–66.
45 Tyssen R, Hem E, Gude T, Gronvold NT, Ekeberg O, Vaglum P.
Lower life satisfaction in physicians compared with a general
population sample: a 10-year longitudinal, nationwide study of course
and predictors. Soc Psychiatry Psychiatr Epidemiol 2009; 44: 47–54.
46 Wall TD, Bolden RI, Borrill CS, et al. Minor psychiatric disorder in
NHS trust staff : occupational and gender diff erences. Br J Psychiatry
1997; 171: 519–23.
47 McManus IC, Winder BC, Gordon D. Are UK doctors particularly
stressed? Lancet 1999; 354: 1358–59.
48 Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of
depression, anxiety, and other indicators of psychological distress
among U.S. and Canadian medical schools. Acad Med 2006;
49 Baldisseri MR. Imparied healthcare professional. Crit Care Med 2007;
35 (suppl): S106–16.
50 Center C, Davis M, Detre T, et al. Confronting depression and suicide
in physicians: a consensus statement. JAMA 2003; 289: 3161–66.
51 Nylenna M, Gulbrandsen P, Forde R, Aasland OG. Unhappy doctors?
A longitudinal study of life and job satisfaction among Norwegian
doctors 1994–2002. BMC Health Serv Res 2005; 5: 44.
52 Firth-Cozens J. Interventions to improve physicians’ well being and
patient care. Soc Sci Med 2001; 52: 215–22.
53 Pullen D, Lonie CE, Lyle DM, Cam DE, Doughty MV. Medical care
of doctors. Med J Aust 1995; 162: 481–84.
54 Taub S, Morin K, Goldrich MS, Ray P, Benjamin R. Physician
health and wellness. Occup Med 2006; 56: 77–82.
Review Download full-text
www.thelancet.com Vol 374 November 14, 2009 1721
55 Thompson WT, Cupples ME, Sibbett CH, Skan DI, Bradley T.
Challenge of culture, conscience, and contract to general
practitioners’ care of their own health: qualitative study. BMJ 2001;
56 Uallachain GN. Attitudes towards self-health care: a survey of GP
trainees. Ir Med J 2008; 100: 489–91.
57 Edwards N, Kornacki MJ, Silversin J. Unhappy doctors: what are the
causes and what can be done? BMJ 2002; 324: 835–38.
58 Wallace JE, Lemaire J. On physician well being-you’ll get by with a
little help from your friends. Soc Sci Med 2007; 64: 2565–77.
59 Firth-Cozens J, King J. Are psychological factors linked to
performance? In: Firth-Cozens J, King J, Hutchinson A, McAvoy P,
eds. Understanding doctors’ performance. Oxford: Radcliff e
Publishing, 2006: 61–70.
60 McManus IC, Keeling A, Paice E. Stress, burnout and doctors’
attitudes to work are determined by personality and learning style: a
twelve year longitudinal study of UK medical graduates. BMC Med
2004; 2: 29.
61 Robinson G. Stresses on women physicians: consequences and
coping techniques. Depress Anxiety 2003; 17: 180–89.
62 Farber NJ, Gilibert SG, Aboff BM, Collier VU, Weiner J, Boyer EG.
Physicians’ willingness to report impaired colleagues. Soc Sci Med
2005; 61: 1772–75.
63 Roberts LW, Warner TD, Rogers M, Horwitz R, Redgrave G. Medical
student illness and impairment: a vignette-based survey study
involving 955 students at 9 medical schools. Compr Psychiatry 2005;
64 Schroeder R, Brazeau CM, Zackin F, et al. Do state medical board
applications violate the Americans with disabilities act? Acad Med
2009; 84: 776–81.
65 Worley LLM. Our fallen peers: a mandate for change. Acad Psychiatry
2008; 32: 8–12.
66 Hampton T. Experts address risk of physician suicide. JAMA 2005;
67 Hendin H, Reynolds C, Fox D, et al. Licensing and physician mental
health: problems and possibilities. J Med Licensure Discipline 2007;
68 McKevitt C, Morgan M, Dundas R, Holland WW. Sickness absence
and ‘working through’ illness: a comparison of two professional
groups. J Public Health Med 1997; 19: 295–300.
69 Baldwin PJ, Dodd M, Wrate RM. Young doctors’ health—II. Health
and health behavior. Soc Sci Med 1997; 45: 41–44.
70 Winston J, Johnson C, Wilson S. Barriers to healthy eating by
National Health Service (NHS) hospital doctors in the hospital
setting: results of a cross-sectional survey. BMC Res Notes 2008; 1: 69.
71 National Patient Safety Agency. National Clinical Assessment Service.
Practitioner Health Programme. http://www.ncas.npsa.nhs.uk/
health/practitioner-health-programme (accessed Sept 14, 2009).
72 The Joint Commission. Comprehensive accreditation manual for
hospitals: the offi cial handbook, 2009. Oakbrook Terrace, IL: Joint
Commission Resources, 2009: 26.
73 The Joint Commission. Sentinel event alert: behaviors that
undermine a culture of safety. http://www.jointcommission.org/
SentinelEvents/SentinelEventAlert/sea_40.htm (accessed July 15,
74 Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and
demographic trends signal an impending physician shortage.
Health Aff (Millwood) 2002; 21: 140–54.
75 Virtanen P, Oksanen T, Kivimäki M, Virtanen M, Pentti J, Vahtera J.
Work stress and health in primary health care physicians and
hospital physicians. Occup Environ Med 2008; 65: 364–66.
76 Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and
coping among orthopaedic surgery residents and faculty.
J Bone Joint Surg Am 2004; 86: 1579–86.
77 Gardiner M, Sexton R, Durbridge M, Garrard K. The role of
psychological well being in retaining rural practitioners.
Aust J Rural Health 2005; 13: 149–55.
78 Grunfeld E, Whelan TJ, Zitzelsberger L, Willan AR, Montesanto B,
Evans WK. Cancer care workers in Ontario: prevalence of burnout,
job stress and job satisfaction. CMAJ 2000; 163: 166–69.
79 Keeton K, Fenner DE, Johnson RB, Hayward RA. Predictors of
physician career satisfaction, work-life balance, and burnout.
Obstet Gynecol 2007; 109: 949–55.
80 Dorsey ER, Jarjoura D, Ruteki GW. Infl uence of controllable
lifestyle on recent trends in specialty choice by US medical
students. JAMA 2003; 290: 1173–78.
81 McMurray J, Linzer M, Konrad T, Douglas J, Shugerman R,
Nelson K. The work lives of women physicians: results from the
physician work life study. J Gen Intern Med 2000; 15: 372–80.
82 Shi L. Managing human resources in health care organizations,
1st edn. Sudbury, MA: Jones and Bartlett Publishers, 2006.
83 Linzer M, Kondrad TR, Douglas J, et al. Predicting and preventing
physician burnout: results from the United States and
Netherlands. Am J Med 2001; 111: 170–75.
84 Wetterneck TB, Linzer M, McMurray J, et al. Worklife and
satisfaction of general internists. Arch Intern Med 2002;
85 Di Matteo MR, Sherbourne CD, Hays RD, et al. Physicians
characteristics infl uence patients’ adherence to medical treatment:
results from the medical outcomes study. Health Psychol 1993;
86 Parthasarathy S. Sleep and the medical profession.
Curr Opin Pulm Med 2005; 11: 507–12.
87 Williamson AM, Feyer AM. Moderate sleep deprivation produces
impairments in cognitive and motor performance equivalent to
legally prescribed levels of alcohol intoxication. Occup Environ Med
2000; 57: 649–55.
88 Gerdes J, Kahol K, Smith M, Leyba MF, Ferrara JJ. Jack Barney
award: the eff ect of fatigue on cognitive and psychomotor skills of
trauma residents and attending surgeons. Am J Surg 2008;
89 Halbesleben JR, Rathert C. Linking physician burnout and patient
outcomes: exploring the dyadic relationship between physicians
and patients. Health Care Manage Rev 2008; 33: 29–39.
90 Cornuz J, Ghali WA, Di Carlantonio D, Pecoud A, Paccaud F.
Physicians’ attitudes towards prevention: importance of
intervention-specifi c barriers and physicians’ health habits.
Fam Pract 2001; 17: 535–40.
91 Frank E, Elon L, Naimi T, Brewer R. Alcohol consumption and
alcohol counseling behavior among US medical students: cohort
study. BMJ 2008; 337: a2155.
92 Haas JS, Cook EF, Puopolo AL, Burstin HR, Clearly PD,
Brennan TA. Is the professional satisfaction of general internists
associated with patient satisfaction? J Gen Intern Med 2000;
93 Arnetz BB. Staff perception of the impact of health care
transformation on quality of care. Int J Qual Health Care 1999;
94 Arnetz BB. Subjective indicators as a gauge for improving
organizational well being: an attempt to apply the cognitive
activation theory to organizations. Psychoneuroendocrinology 2005;
95 Dunn PM, Arnetz BB, Christensent JF, Homer L. Meeting the
imperative to improve physician well being: assessment of an
innovative program. J Gen Intern Med 2007; 22: 1544–52.
96 Gardiner M, Lovell G, Williamson P. Physician you can heal
yourself! Cognitive behavioral training reduces stress in GPs.
Fam Pract 2004; 21: 545–51.
97 Le Blanc PM, Hox JJ, Schaufeli WB, Taris TW, Peeters MCW. Take
care! The evaluation of a team-based burnout intervention
program for oncology care providers. J Appl Psychol 2007;
98 Rowe MM. Teaching health-care providers coping: results of a
two-year study. J Behav Med 1999; 22: 511–51.
99 Rø KEI, Gude T, Tyssen R, Aasland OG. Counselling for burnout
in Norwegian doctors: one year cohort study. BMJ 2008;
100 Jones JW, Barge BN, Steff y BD, Fay LM, Kunz LK, Wuebker LJ.
Stress and medical malpractice: organizational risk assessment
and intervention. J Appl Psychol 1988; 73: 727–35.