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Clinical Reviews


The unbearable unhappiness of the ObGyn: A crisis looms

One in every five physicians feels dissatisfaction with a career in medicine—some so strongly that they abandon the workforce. An insider proposes solutions to burnout.

December 2008 · Vol. 20, No. 12

IN THIS ARTICLE

Dr. Weinstein has no financial relationships relevant to this article.

“I CAN’T GET NO SATISFACTION”—Mick Jagger and Keith Richards, 1965

“FOR THE TIMES THEY ARE A-CHANGIN’”—Bob Dylan, 1964

The lyrics of two songs written more than 40 years ago are an excellent way to describe today’s physician workforce. Regrettably, many physicians who grew up listening to these performer-philosophers have yet to heed the words of Bob Dylan. Instead, they echo the sentiments of Mick Jagger and Keith Richards without doing much to correct the problem.

Why the decline in work satisfaction? Many reasons have been cited, including:

  • loss of autonomy
  • economic pressures
  • an increasing degree of government and insurer control over practice
  • the liability crisis
  • a divergence between professional and personal expectations
  • physicians’ own high career expectations
  • a desire for more time for family and self. 1

The growing level of dissatisfaction with the practice of medicine has, clearly, reached crisis level: Twenty percent of all physicians report that they are dissatisfied with their career. 2,3 And lack of fulfillment appears to be developing much earlier in the life of a physician than has so far been appreciated. Not only is it showing up in residents, job dissatisfaction is evident even among medical students. It is quite revealing—and depressing—that 40% of young physicians would choose not to go to medical school if they had to choose again.

In this article, I examine the characteristics of the dissatisfied physician, explain the apparent reasons for this lack of fulfillment, and propose a number of steps that can be taken to salvage the situation, lengthen the time that a physician works, on average, and add flexibility and variety to work life.


Ultimate effect of dissatisfaction? Loss of a physician

An unhappy physician is two or three times more likely to leave the profession or decrease the number of hours worked than a satisfied physician is. 4 And when a physician leaves the workforce, we lose a valuable resource. The estimated replacement cost for a physician in 1992 to 1999 dollars was $250,000, and that cost is at least 50% higher today. 5,6 Besides the monetary loss, there is disruption to other members of the practice group and to patients when a physician leaves the profession.

Landon and colleagues found that the average age of a physician working full-time was 47 years, compared with 53 years for a physician who was working fewer than 20 hours a week and 63 years for a physician at retirement. 4 However, these data are approximately 7 years old; current figures are likely to show curtailment of work hours at even younger ages.

It is not realistic to expect that 1) the educational system will increase medical school class size and 2) enough physicians will finish training and develop a mature practice in the time necessary to offset the number of physicians now altering their workloads or exiting the workforce.

Does gender influence the satisfaction rate?

The profession of medicine has changed strikingly over the past 20 years. Once male-dominated, it now is gender-equal and, in some specialties, female-dominated.

This rapid gender shift in medicine has received much of the blame for the decline in physician satisfaction. However, data suggest that, among full-time academic faculty who do not have children, productivity and career satisfaction are the same for women as for men. 7 A recent study of internists found few gender differences in work-life balance, work hours, and attitudes toward patient care. 8

Among surgeons, an equal percentage of each gender believes that the work schedule leaves too little time for personal and family life. 9 Although it has been suggested that women prefer to work fewer hours than men, evidence indicates that younger men have the same desire to work less and spend more time with family. 10

That said, there are some gender-related differences in medical workforce characteristics:

  • Women reduce their clinical activity during childbearing and childrearing and retire 5.5 years earlier than men do 4
  • In obstetrics, women younger than 40 years are four times more likely to reduce work hours or completely stop practice than male obstetricians are 11
  • Among surgeons, 90% of women live in dual-career households, compared with 50% of men 9
  • When the surgeon is male, children are cared for by spouses in 63% of households; when the surgeon is female, children are cared for by an employee in 88% of households 9
  • Among surgical subspecialists, women are more likely to be divorced or separated and to have fewer or no children; 34% spend 21 to 40 hours weekly on household management. 12

Despite these differences, a review of the literature on physician dissatisfaction suggests that the gender shift in medicine is not responsible for the growing level of dissatisfaction.

Is there a shortage of physicians?

After much talk of an impending physician shortage, many medical schools have increased class size, and a number of new medical schools recently opened or are on their way to opening. The Association of American Medical Colleges recommends that medical school class size increase 30% by 2015. 32

Some experts believe that there will be a dearth of generalist physicians; others think that specialists will be in short supply.

Possible causes of the shortage

The coming physician shortage has been attributed to a number of variables, including:

  • an aging population, which will require a greater level of health care
  • aging physicians, with as many as 30% of the current workforce expected to retire during the next 5 to 10 years
  • an increase in the number of female physicians who work fewer hours than their male counterparts
  • an increase in physicians from Generations X and Y, who place greater emphasis on lifestyle and personal time. 33

Cooper, who has written extensively on physician workforce numbers, believes that placement of the Medicare-funded graduate medical education (GME) position cap approximately 10 years ago has been the major driver of the physician shortage. Improvement will come, he says, only when this cap is lifted or altered. 34

Are there enough doctors?

The number of physicians per capita is at its highest point in 50 years in the United States, yet the Council of Graduate Medical Education predicts a 10% shortfall by 2020. 35 When regions with a high supply of physicians are compared with regions with a low supply, outcomes are the same, and patients do not perceive any physician shortfall. 36,37 It is interesting that, in regions where there is a high supply of physicians, physicians perceive there to be greater difficulty in providing the quality of care they desire for their patients. 38

A greater supply of physicians leads to more tests and procedures and higher costs. 37 Goodman and Fisher believe that having more specialists decreases the flexibility of the physician workforce. They also believe that the GME cap should be maintained, funding should be reallocated to the more cognitive specialties, and the current payment system should be reformed. 35 (Any physician who has attended a hospital medical executive committee meeting knows that reallocation of resources to cognitive specialties will never happen: Hospitals want more surgical procedures to boost their bottom line.)

A review of the many studies and opinions published about current work-force numbers and future needs makes it obvious that very little evidence exists to support any of the recommendations made by experts. Almost all studies mention adding to the workforce with minimal discussion about how to keep the current workforce from leaving—a much better use of resources.

Age is the determining factor

The Baby Boomer generation (born between 1946 and 1964), which had largely controlled all aspects of medicine, especially leadership roles, is rapidly being replaced by physicians from Generations X and Y (born between 1965 and 1980, and 1981 and 2001, respectively), who value personal time and lifestyle much more than “Boomers” have. 13

These younger physicians demand flexibility and variety in their careers. They grow dissatisfied when these aspects of their work lives fall out of their control. And when it comes to choosing a specialty in which to practice, these physicians see a balanced lifestyle as the key variable. 13

Much of the discussion of dissatisfaction in medicine has contrasted Baby Boomers with subsequent generations. The Boomer physician typically has a traditional marriage, with the spouse doing most of the parenting and managing household duties. The Boomer physician is more likely to be male, work long hours, and see professional life as the overall driving force of daily existence.

However, the perception that a Boomer physician is immune to career dissatisfaction is incorrect. Dissatisfaction and departure from practice are directly related to age, with those who are 50 or older more likely to experience them. 14 In another study, age and dissatisfaction were the principal factors positively associated with intention to leave practice. 15

For Generations X and Y, time is the overarching issue

Generations X and Y physicians are an equal mix of genders, with the majority of couples having dual careers. Their desire for balanced work and family life has made time the primary issue in rising dissatisfaction with medicine. There is less time for each patient encounter, more time required for documentation to justify reimbursement, more time necessary to deal with practice management, and less time to handle family issues—especially personal well-being. 16 These issues have also contributed to rising dissatisfaction among Baby Boomers.

Enter, the 80-hour workweek

In 2003, the Accreditation Council for Graduate Medical Education instituted the 80-hour workweek in an attempt to improve patient safety and the lifestyle of physicians in training. Many senior physicians believed that work-hour restriction would erode the quality of training, but this does not appear to have occurred.

Work-hour restriction among surgical residents has had no effect on academic performance but has markedly decreased psychological distress. 17 Among medical residents, work-hour restriction has improved career satisfaction and decreased emotional exhaustion—but residents perceive restrictions to have impinged on patient care and resident education. 18 Although surgical residents believe that restriction has reduced overall stress, improved quality of life, and provided time in which to manage their personal life, they are concerned about the limitation on exposure to patients—yet 96% of these residents would not be willing to add an additional year to their training. 19

There is evidence that about one third of a resident’s time is spent performing activities of marginal or no educational value. 20 By eliminating these activities and making better use of simulators and patient surrogates, the workweek could be reduced even further, allowing the physician in training more time for interaction with patients and providing a better balance between work and personal life.

Burnout is widespread

If the goal is to retain physicians in the work-force, it is more important to reduce dissatisfaction than to increase satisfaction. Why? People who are dissatisfied are more likely to change what they are doing than those with any level of satisfaction. 4

Continued...
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