According to Tait Shanafelt, we are currently in the era of physician well-being he calls “Well-Being 1.0”, an era “characterized by knowledge and awareness.”1 After the awakening that began around 2005, we know more about healer well-being and the consequences of healer distress, and there have (sometimes) been changes made in our workplaces.
So why, 20 years later, does it feel like we haven’t made much progress?
Dr. Shanafelt proposes progress will accelerate when we are able to move into the next era of physician wellness, “Well-being 2.0”, which will be characterized by “…a mindset of physician-administrator partnership to create practical and sustainable solutions [with] acceptance that physicians are subject to the same human limitations that affect all human beings, with attention to appropriate staffing.”1
But there is a big problem.
Physicians and administrators aren’t partners.
What does it mean to be partners?
The word “partner” comes from the Latin partitio. It includes the idea of dividing (partitioning) and sharing that which is divided. Whether it is our partner at home, our clinical partners at work, or our dance partners, a partnership is always defined by a common goal, equal standing for the partners, honest communication, and true collaboration. You can’t be a partner with someone who has all the power and who sees their mission differently from yours. I know there are exceptions, but most physicians (and other healers) do not feel they are in a partnership with the leaders of their organizations.
It wasn’t always this way.
The change is due to a complex set of variables, the most important of which is how the “business” of medicine has evolved. The marketization of medicine began a mere 40 years ago and has evolved into today’s medical-industrial complex which Ricardo Nuila calls “Medicine Inc.”2 Prior to Medicine Inc, physicians and administrators were partners with a shared goal and a classic division of labor; Physicians (and other healers) provided the care, and administrators were stewards of the resources needed for that care. All this changed when medicine became a commodity, when marketization (taking medicine to the market for shareholders) and then corporatization of medicine became the norm.
Let’s be clear. This is not some big conspiracy. The administrators who work for Medicine, Inc. are “doing what business does” as a friend of mine said to me recently. They work for systems designed to create profit for shareholders. Within the constraints of regulations and blatant violations of ethical mandates, profit is their primary objective. But it’s not the primary objective of the physicians they “manage”. And it’s this perception – that the organizations that employ us put profit before people – that is almost uniformly recognized as the most important root cause of physician (and all other healer) distress.
The system is broken, and it is breaking us
The data on healer distress is appalling. At the tip of the iceberg are the statistics we hear quoted in every discussion on healer well-being, the data that makes us almost physically ill – the deaths and near deaths of our colleagues. When you add in the other causes of physical, psychological, emotional and spiritual suffering, it’s no wonder we feel broken.
It’s not surprising that so many people are leaving medicine.
But there is another way.
As tired and burned out as we are, there are people who need us now and will need us in the future. We have to find ways to show up and keep showing up for them while we work to change the system, by sequentially moving one previously unmovable problem at a time.
Be a healthy lever of change
Give me a lever long enough and a fulcrum on which to place it, and I shall move the world. Archimedes
In Wellness 1.0 we became aware of the issues. As we attempted to move into Wellness 2.0 we discovered a major barrier to change. We aren’t partners with administration…and they hold most of the power.
I’m convinced we are going to have to more or less skip Well-being 2.0. But, even as we recognize that the leaders of Medicine, Inc don’t see the world through the same lens as we do, we must not fall into the trap of “us and them” when it comes to working together. Both sides have to keep listening. We need to keep our doors open and conversations going. I suspect, if we did the studies, we would find significant distress and burnout among healthcare administrators, too. Just knowing this may help us encounter difficult moments (and difficult people) more effectively.
If we are to be healthy levers of change (a concept I learned from Dr. Wendy Lau) we need a new way to think about this.
We need a grass-roots revolution.
We need “Well-Being 3.0”, an entirely different approach composed of three actions every healer will be called to adopt:
- Practice compassion.
- See clearly and speak the truth; Learn to say “That’s not normal.”
- Decide who you work for.
Practice Compassion
Compassion is the first major tool we need to create change for our patients and ourselves.
Compassion is related to but quite different from sympathy and empathy, a difference that is important to understand. The words sympathy and empathy arise from the same Greek root – pathos which means “suffering”. When we feel sympathy we feel sorry for someone. When we feel empathy we feel the suffering with them.
Compassion, on the other hand wells up in us when we are moved to do something to relieve their suffering. The distinction is important. Empathy that is not transformed into compassion can be harmful. As Joan Halifax teaches, “Healthy emotional empathy makes for a more caring world. It can nurture social connection, concern, and insight. But unregulated emotional empathy can be the source of distress and burnout; it can also lead to withdrawal and moral apathy.” 3 Fortunately, we can learn how to practice compassion, and (Good news!!!) compassion does not and cannot lead to distress.
The best way to learn and practice compassion is with Joan Halifax’s powerful pneumonic “GRACE”. This five step practice is described in more detail in Wendy Lau’s book, Inner Practice of Medicine: Guide to Becoming True Stewards of Health, which I recommend to everyone in medicine. 4
The G of GRACE – Gathering attention.
“…compassion cannot arise when our attention is not present.” 4
It’s human nature to think about the last patient you saw and the test you forgot to order as you walk into the next patient’s room on rounds. The first step of this five step process addresses our innate tendency to be “distracted, dispersed or divided.” “Gather your attention” means consciously deciding to be present, here and now. That’s all. (Easier said than done, but that’s why it’s a practice)
The R of GRACE – Recalling Your Intention
“Then when you next find yourself standing in the hallway before seeing your next patient, first take a breath in to gather your attention and a breath out to drop your attention into your body, feeling your feet on the ground (G of GRACE). Then ask yourself, “Why am I doing this? What is my intention for this next appointment? Why am I here?.” 4
The second step is to take a moment to remember that you aren’t rounding or seeing a patient in clinic to write a note in the electronic medical record or order a test. You are seeing them for all the reasons you chose medicine in the first place – to heal when you can and relieve suffering when you can’t. Once you have gathered your attention, take a moment to remember why you are here.
The A of GRACE – Attuning to Self and then to the Other
“Yet what is required for a more compassionate and humanistic approach is not to deny our emotional experience, but to learn to process it effectively.” 4
We are embodied people, but we live in our heads. In this third step pay attention to what emotions and stresses you are bringing to the encounter (and where you are feeling them) so they can be acknowledged and processed. Then, and only then, turn to the human being in front of you who is there for your care and attune to their emotions and stresses.
The C of GRACE – Considering What Will Serve
“The C of GRACE builds on a foundation of openness and curiosity to inquire into “What will really serve?” It also engages our expertise, integrity, and sensing into the alignment (or misalignment) of our values, commitments, choices, action, and memories.” 4
We’ve all had the patient with a minor complaint that didn’t make sense… until we found out that they had been thrown out of their apartment and what they really needed was some time with the social worker. Sometimes the obvious is not the answer to what the patient really needs.
The E of GRACE – Engaging and then Ending
Engaging is the easy part. After deciding what we need to do to serve the person in front of us, we do it. “Ending” is not as easy since it is not a concept we discuss or have been taught. Dr. Lau proposes four steps to end the encounter:
- See how it feels to let go now.
- What needs to be done?
- Acknowledge the work you have done.
- Cultivate a sense of gratitude for yourself and the patient.”4
In other words, ending the encounter is a form of debriefing where you review what you did, and what still remains to be done, all while feeling gratitude for the patient and yourself.
“That’s not normal”
“They are going to cut my clinic visits from 15 to 12 minutes. It’s impossible for me to see patients in 12 minutes, but there is nothing I can do.”
Oh yes, there is.
Name it.
Turn to the colleague next to you and say out loud, “That’s not normal.” If you are alone, at least say it to yourself… preferable out loud but if not, at least in your thoughts.
- It’s not normal to not see a dentist for three years.
- It’s not normal to rush a visit with a tearful and frightened patient because your clinic is so overbooked.
- It’s not normal to have more than 10 years of professional training to spend hours at home typing and clicking buttons in the EMR.
- It’s not normal to stay up all night and then work a full day the next day.
- It’s not normal to pronounce a child in the ED, hold their weeping mother briefly, and then run to clinic because you’ve just been paged for the fifth time that you are late.
Decide who you work for.
The third step is for all of us – individually and collectively – to consciously and deliberately decide who we work for, remembering that who employs us is not necessarily who we work for.
We are employed by the systems who pay us.
We work for our patients and our trainees.
Be part of the 17%
We can do this.
It doesn’t take a majority of people to change in order to shift a culture, a business, or a way of thinking. Sociologists have shown us that there is a classic “tipping point” for the beliefs and behaviors of a group that is somewhere around 17%. For example, when 17% of the people around you bought smartphones is probably when you decided you needed one (unless you were an early adopter). If 17% of your group thinks the new call schedule is great, there probably won’t be much dissent. This is part of our psychology and part of how groups function.
All of this to say… If only 17% of us practice compassion, bear witness when what we are asked to do is outside of the norm, and remember who we really work for, Medicine will change. To paraphrase Margaret Mead, “Never doubt that a small group of thoughtful committed healers can change Medicine. In fact, it’s the only thing that ever has.”
Let’s get to work.
2. Nuila R. The People’s Hospital: Hope and Peril in American Medicine. Scribner; 2023.
