‘We cannot pour from an empty cup:’ Prioritizing work-life balance in medicine
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When it comes to work-life balance, providers in the past skewed more toward work than life.
However, shifting demographics in the medical workforce, increasing capacity for communication and the COVID-19 pandemic have fundamentally altered that calculus.
Source: Maryam Lustberg, MD, MPH
“The expectation and acceptance that doctors should work all day and all week with no time for themselves and their families has definitely changed,” Maryam Lustberg, MD, MPH, director of the Breast Center at Smilow Cancer Hospital at Yale New Haven, and chief of breast medical oncology at the Yale Cancer Center, told Healio | Infectious Disease News. “There is a definite recognition of the risk for burnout and that no job is worth the sacrifice of family and health.”
Reasons for this apparent generational divide vary. One easy narrative is that older doctors are more willing to work, whereas younger doctors are not. However — as is often the case — the reality is likely more complicated.
“People in my generation are not opposed to working hard,” Lena K. Makaroun, MD, MS, an assistant professor of medicine in the division of geriatric medicine at the University of Pittsburgh School of Medicine, said in an interview. “You do not go into medicine if you are afraid of working hard.
“This is not a cushy field,” she added. “What I think is true of our generation is that we make sure to appreciate and value our lives holistically, which includes work, but which also includes our families, hobbies and social activities.”
That said, there is more at play than recent changes in attitude and priorities. According to Dike Drummond, MD, CEO of TheHappyMD.com — which offers coaching to physicians to prevent or recover from burnout —there are important structural differences between the professional worlds that providers in the baby boom generation cut their teeth in vs. that of their younger counterparts.
“Resident work hour restrictions mean that they graduate with one-third less total clinical experience and are never pushed as hard or abused as much as those who graduated in the days without work hour restrictions,” he said. “They are not as harshly programmed to overextend themselves and were trained in an environment with existing wellness programs.”
However, despite this background, younger generations in some ways face far more demands than their predecessors, according to Leah M. Katz, MD, MPH, assistant professor of radiation oncology at Columbia University Irving Medical Center.
“Retired physicians who were not as connected electronically do not realize how much administrative work we have to do simply to communicate with our patients,” she said.
Patients today have no shortage of ways to contact their physicians, even beyond calls, texts or emails, Katz added.
“There are also EMR systems that allow for direct communication from patient to physician,” Katz said. “You can easily spend 2 or 3 hours a day — and sometimes 4 or 5 hours — just responding to all of this. It is a completely different ecosystem.”
This “response fatigue” exacerbates the physical fatigue of the job itself, according to Katz. However, increased communication is not the only important recent shift.
“Medicine used to be male dominated, and ideally more women in medicine would imply a sharing of household duties, but this is not necessarily the case,” Katz said. “A large body of evidence shows that even in dual-physician households, as much as 80% of the housework and child care duties still fall on women.”
In the past, infectious disease physicians have cited issues specific to ID that negatively impact their work-life balance, including heavy patient volumes, excess documentation requirements and lower reimbursement rates compared with other specialties.
For all these reasons, physicians are reassessing whether the traditional way of practicing medicine, combined with the current socio-organizational landscape, is still a healthy and sustainable model, according to Aline Charabaty, MD, associate professor of clinical medicine at the Johns Hopkins School of Medicine and clinical director of the IBD Center at Johns Hopkins-Sibley Memorial Hospital.
“As physicians, we cannot pour from an empty cup,” she said. “A healthy, rewarding personal life is as important, if not more important, than our career.”
Many hospitals, health systems and individual practitioners have come around to the idea of allowing employees to include more life in their work-life balance. However, this remains far from universal in the United States health care landscape. Understanding shifting priorities, changing demographics and ongoing concerns can help larger organizations retain staff and individual practitioners lead more balanced and fulfilling lives.
‘Constant distraction’
In a 2022 paper published in Frontiers in Psychology, Kerksieck and colleagues described the problems stemming from of increased access to physicians, which has accelerated with each advance in communication technology and was sent into overdrive during the COVID-19 pandemic.
According to the authors, developments in digitalization have increased the “interference of the work and nonwork life domains,” putting pressure on many to continuously manage engagement with patients.
“Incoming communications are a constant distraction,” Katz said. “The volume is almost incomprehensible.”
Katz acknowledged that the influx of communications means patients can be more engaged and informed. However, although more informed patients are preferable to the alternative, they can also command more time.
Meanwhile, shifting work habits triggered by the pandemic exacerbated, essentially, all of the above.
“With everyone working from home and few options for social activities, everyone started to expect everyone else to be available all the time,” Katz said. “There are no real boundaries between working and not working.”
According to Makaroun, far from making their lives easier, the promise of technology — that it would free up providers to have more open communication with patients — has devolved into something decidedly less helpful.
“The promise of technology was that it would take care of the technical aspects of our jobs and allow us to communicate more with patients in the clinic,” she said. “But it has not delivered on that promise. In many ways, technology has taken the personal connection out of practicing medicine.”
Another disruptive shift in the practice of medicine — not necessarily triggered by the pandemic, but certainly exacerbated by it — can be described as a “backlash” against the scientific community in general and public health officials specifically, Makaroun added.
“In the immediate moment of COVID, the health care profession was seen as an essential workforce,” she said. “But in the medium- and long-term, there has been this backlash against the scientific community and public health officials. That has evolved into distrust of medical professionals. It takes a toll.”
However, COVID-19 is just one worry among many, according to Makaroun.
“When my parents were practicing medicine in the ‘80s and ‘90s, it was a more optimistic time in the Western world,” she said. “Now there is just a lot of dread among my generation as a whole — about climate change and political instability and other factors. When you are optimistic about the future, you might be more willing to delay gratification because you are confident you are going to have more time to enjoy things in the future. But now, with so much uncertainty for the future, the present is more precious.”
However, possibly the most critical difference between baby boomers and later generations that grew up with digital communications, at least regarding the workforce, is that the younger cohort is more likely to voice their concerns — big and small — publicly, according to Drummond.
“The current generation of doctors is also much more active on social media, so you can witness their struggles and burnout in the comments on massive Facebook groups,” he said.
‘Oh, hell no’
With two out of five active U.S. physicians set to reach retirement age within the next decade, burnout is unlikely to be alleviated. According to data from the Association of American Medical Colleges, 45% of American physicians are aged older than 55 years. Although the estimates vary, a shortage of more than 100,000 physicians in the U.S. is predicted by 2030.
“This is a massive underestimate,” Drummond said. “There are disastrous demographics for our aging physician workforce. This makes it so difficult to prioritize work-life balance that we are seeing waves of doctors leaving the practice that will only worsen over time.
“We lost 100,000 doctors who quit practice in 2023 and we will lose at least 100,000 more in 2024,” he added.
The COVID-19 pandemic did not help.
“Many senior physicians retired in recent years, either because they could not financially sustain the increased administrative burden, or because of the pandemic, or both,” Charabaty said.
An additional concern pertains to staff who are neither MDs nor DOs, according to Drummond.
“Short staffing of nurses is causing ER backups of immense proportions in many cities around the country right now,” he said. “Many young doctors who came through restricted residency programs are looking at these conditions and saying, ‘Oh, hell no,’ and walking away.”
The impact on work-life balance is clear.
“Everywhere, you see physician services or call rotations that are missing one or two of their senior and hardest working members. At the same time, they are missing two float nurses and an MA,” Drummond said. “Everyone must work themselves to exhaustion every day just to make sure the patients are seen.”
This is where the “programming” of older physicians — to solider on through the shortages — comes into play, according to Drummond. However, this tendency can reinforce some negative behaviors among administrators, he said.
“When you are a good doctor and you show up when you are short staffed and see the patients no matter how hard it is to get through the day, that looks really good on the profit and loss statement,” Drummond said. “The CFO will look at the numbers from your department and pat the leader on the back for running a tight ship. There is a massive financial disincentive to staff appropriately, and there is no place to find the staff that are needed for the reasons above.”
Katz, meanwhile, argued that there is in fact an incentive for both health systems and providers to work toward better satisfaction among employees.
“Happy doctors produce better patient outcomes,” she said.
As medical societies and professional organizations grapple with retirement and replenishment, another demographic shift in the workforce is impacting work-life balance priorities — the increased proportion of women in medicine.
An ‘impossible position’
In a 2019 paper published in the International Journal of Women’s Dermatology, Raffi and colleagues surveyed 127 women in dermatology about work-life balance issues. Results showed that a significant proportion of respondents required household help in the form of nannies to perform chores.
“The professional women in our cohort may be balancing work and life at the expense of personal physical and mental health with little time to exercise and fewer hours of sleep per night,” Raffi and colleagues wrote.
This phenomenon is seen across specialties. In a 2021 paper published in Open Heart, Castles and colleagues surveyed 452 health care providers regarding work-life balance factors in cardiology. Results showed that women in cardiology worked more hours and were more likely to be on call than women in other specialties. They also were less likely to agree that they led a balanced life, or that their specialty was female- or family-friendly.
“A lot of female physicians are put in an impossible position,” Katz said. “Some of us are lucky to have full-time child care, but many who have their children in day care are constantly stressed about pick-up times and excess costs. So many women do not have options, which inhibits their ability to advance in their careers.”
Although some hospitals and health systems offer day care or are generally more understanding about these challenges, this type of assistance is still not the norm.
“Women have been particularly dissatisfied with the current medical model and affected by burnout,” Charabaty said. “There is an excessive burden placed on them to both excel in their medical career while still being responsible for most of the domestic and parenting activities. Delayed plans to start a family, and the lack of fair and comprehensive parental leave policies, add barriers toward a satisfying work and life integration.”
In addition to these stressors, on average, women in ID are paid less than their male counterparts, regardless of where they work. According to the results of a survey conducted by the Infectious Diseases Society of America published in 2018, compensation for women in ID was less than that of men if they owned a private practice, were employed by a private practice or hospital or worked in research or public health.
‘Freedom and flexibility’
All of these issues can culminate, ultimately, in physicians feeling powerless in their positions.
“There is a lack of control over the way physicians can practice medicine today,” Makaroun said, noting not just the increased administrative burden, but also more documentation and seemingly constant oversight from nonmedical personnel. “There is little freedom and flexibility to use our training and intuition to manage patients how we see fit.”
This creates the sense that medicine is a job rather than a calling, she added.
“We went into health care in the first place because of some drive or passion to help people,” Makaroun said. “When our autonomy is removed and we are treated like employees, it makes sense that we are less willing to sacrifice ourselves because we are not allowed to practice in a way that is fulfilling and satisfying.”
For Lustberg, it is important for physicians to recognize that the onus of creating work-life balance is not solely on themselves.
“I want to make sure we highlight system problems and prioritize these over what any one person can do,” she said. “For example, ensuring that very early meetings, late meetings and weekend emails are kept at a minimum can be low-hanging-fruit changes that can very quickly change organizational culture.”
According to Drummond, every organization that employs physicians must have an organizational well-being strategy that should include five components.
“These include education, social and cultural interactions outside of work hours, crisis management, stress-reducing process improvement, and a world-class communication and awareness campaign so everybody knows what is being done to protect their health and happiness,” he said.
Having “meaningful connections” in the workplace is key, according to Charabaty.
“Workplaces have to embrace a culture that values physicians’ autonomy and input regarding decisions that affect their practice, and provide comprehensive staff and administrative resources so that physicians can focus on what they do best and have trained for — providing high-quality care to patients,” she said.
Such resources include adequate administrative time to catch up on EHR and clinical work, which prevents having to take work home, as well as staff and financial support to streamline day-to-day function, a flexible work schedule, adequate vacation and CME time, fair and comprehensive parental leave policies, a reasonable call schedule, and effective support for professional growth within the workplace.
However, until hospitals and health systems integrate these procedures universally, it is largely up to individual providers to define their own boundaries between work and life.
‘Rekindle’ a sense of community
Although no one person can influence some of the large, systemic issues that may be causing the sense of dread that Makaroun referenced — for example, climate change — it may be possible for individual providers to make an impact on the health systems in which they work.
Kerksieck and colleagues suggested that providers need to be “proactive” about defining their own boundaries.
“A big thing for physicians to do is have good communication with their team,” Katz said.
Just as health systems should be cognizant of scheduling meetings before or after certain times, individual providers should also communicate their own meeting time boundaries.
“You can also let your team know that you should be called on your cell phone, rather than sent an electronic communication, if there is a patient emergency,” Katz said. “This allows you to turn off your email but keep your phone close in case of a situation that requires your immediate attention. Then you can focus on the administrative work or whatever else you need to do.”
Turning notifications off on the phone can also help, as can setting personal boundaries for when to look at emails and other electronic communications, according to Katz.
“This allows you to actually get work done and focus on patient care,” she said.
Apart from tech solutions, Katz said exercise is a critical component of self-management.
“Exercise is huge to relieve stress and feel energized,” she said.
Exercise can go hand-in-hand with mindfulness, according to Lustberg.
“Understanding and reminding yourself each day what values and goals are important to you can help,” she said. “I was sitting in clinic on a Friday evening and decided to leave a bit earlier. Did everything get cleared out in my in basket? No. However, I cleared out the urgent things and the rest I caught up on early next week.”
Additionally, sometimes it is important to simply accept that the job is difficult, according to Lustberg.
“Yes, I try to block my time better,” she said. “Yes, I try to say ‘no’ more. But there are times when I cannot.”
That said, burnout reduction efforts that focus on the individual — such as advising people to shut off emails or do yoga — can only go so far, according to Makaroun.
“In reality, the problem is not with individuals but with the system, and the solutions to address burnout therefore have to be system changes,” she said. “It’s about much more than people managing stress better or peer support, even if that’s one part of it.”
She added that the issue of “the growing disconnection between doctors” must also be addressed.
“I would suggest trying to rekindle some sense of community among health care workers,” Makaroun said. “When we feel connected to one another, we can support each other and feel connected to the work.”
[Editor’s note: This story was originally published by Healio Rheumatology. It has been updated slightly for an ID audience.]
- References:
- AAMC. Physician specialty data report. https://www.aamc.org/data-reports/data/2022-physician-specialty-data-report-executive-summary. Accessed April 26, 2024.
- Castles AV, et al. Open Heart. 2021;doi:10.1136/openhrt-2021-001678.
- IDSA. 2017 Compensation Survey. http://www.idsociety.org/uploadedFiles/IDSA/Manage_Your_Practice/Compensation/2017%20IDSA%20Comp%20Survey_REPORT_Final.pdf. Accessed April 25, 2024.
- Kerksiek P, et al. Front Psychol. 2022;doi:10.3389/fpsyg.2022.892120.
- Raffi J, et al. Int J Womens Dermatol. 2019;doi:10.1016/j.ijwd.2019.07.001.
- Woodward R, et al. SAGE Open Med. 2022;doi:10.1177/20503121221085841.
- For more information:
- Aline Charabaty, MD, can be reached at acharab1@jhmi.edu.
- Dike Drummond, MD, can be reached at dikedrummond@gmail.com.
- Leah M. Katz, MD, can be reached at lk2563@cumc.columbia.edu.
- Maryam Lustberg, MD, MPH, can be reached at maryam.lustberg@yale.edu.
- Lena K. Makaroun, MD, MS, can be reached at LKM35@pitt.edu.
In case you missed it
In the February 2023 issue, we asked Eli Wilber, MD, and Ishminder Kaur, MD, if ID physicians have a good quality of life. Click here to read their responses.
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