It was a quiet year….

Two Thousand Thirteen was a quiet year for my blog. But it was a busy year of doctoring with 10-12 hours in clinic most days, an additional 2-3 at night, plus a few hours on most weekends. [We can analyze why over a drink sometime]. Of many sacrifices a full-time primary care practice necessitates, blogging was one of them. Also falling victim to the work schedule were guitar lessons, dinners with friends, and medical conferences I had planned to attend. Reading? Shopping? All of those seemed like luxuries. I missed writing on this blog, which was a nice way for me to reflect on this complex world of medicine.

However, in 2013, I did continue to work out regularly (for my own sanity, and – yes – I think of this as an achievement considering my schedule) and I wrote regularly for the Seattle Times as a columnist for the On Health section of the paper. I continued my position as a committee member with the Women in Medicine group of the Washington Chapter of American College of Physicians, and we hosted various increasingly successful events during the year. I continued to serve as an advisory board member for an IT company, learning more about the complexities of IT systems, networking, and EHRs. I mostly listened on Twitter, often inspired to write posts, but lacked the time and energy to put my best work into it. However, it was wonderful to keep up with some of writing of some of the colleagues I admire. And the best part of 2013 was that I had the honor of having one of my pieces published in a book (more on that in a future post).

We are fully into 2014 and New Years’ Day already feels like it was long ago. My schedule has not changed, but there is one thing I know for sure – this year won’t be so quiet for my blog.

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Balancing – Not a New Act

The concept of “work-life balance” seems newer to the field of medicine, which trails many other professions that have already incorporated creative and flexible options for work with the advent of telecommuting. Still, this term has been present now in medical circles for long enough that to suggest otherwise would be to appear out-of-touch…which is just what anesthesiologist Dr. Karen Sibert did recently when she wrote a New York Times Op-Ed suggesting that female physicians who worked part-time were doing a disservice to US healthcare system and not fulfilling a moral obligation to their patients.

Many physicians responded quickly and critically to the article in comments, tweets, and blogs. Some valid points were raised, including ones asserting that “balanced” physicians are better physicians and others that pointed out that the article placed an inordinate amount of blame for the current – and future – shortage of primary care doctors on female physicians who work less than full-time.

Putting aside the fact that the definitions of full- and part-time work are somewhat arbitrary (variable across employers, professions, and countries) the truth about work-life balance is that it is actually not a new concept. In fact, I would argue that Dr. Sibert, who completed her training in the 1980s and raised four children while working full-time as an anesthesiologist had it. It was just one that worked for her.

In its purest definition, work-life balance has always been present in some form or another. What changes over time – individually and societally – is the value of the items being measured on the scale.

 This is not to say that there are no seemingly unbalanced situations out there (like an older doctor I knew who was in the office till 8 or 9pm almost every night). But wouldn’t I be assigning my own value system to the variables in his equation for balance? That older physician’s iteration of work-life balance worked for him and his wife. If it didn’t, things would shift at some point, similar to the law of conservation of energy in physics. Today’s “work-life balance” is a representation of a definite societal shift in the value of the items being measured (work and life and let’s add in happiness, as if it was work-life-happiness balance).

Has medicine failed to provide enough $, stuff, and status to motivate full-time work?” asked one physician on Twitter.

A poignant conversation on Twitter briefly touched on some other potential factors that might be fuelling a trend of physicians desiring part-time work (which is not limited to female doctors or physician-parents, by the way). Whenever one looks at a career or job, there is a measurement of the trade-offs (benefits, commute, status, compensation, hours, prospects for advancement). Almost every one of us does this, irrespective of profession/job. It might be possible that, in the case of the field of medicine, interests outside of practicing medicine have gained value or the rewards of practicing medicine have diminished. Or both.

Based on my discussions with other primary care doctors, it appears primary care is following the law of diminishing returns or, in the case of physician burnout, even the law of negative returns. With a compensation model that favors proceduralists, an increasing workload to keep up overhead, a sense of dispensability from some employers and the public, anti-doctor sentiment (which is witnessed in social circles despite the presence of physicians in them), and monthly debt repayments equivalent to a mortgage for some, it wouldn’t be hard to imagine that some primary care physicians – a subset of a group of bright individuals who tends to delay happiness for the sake of training – might feel quite disheartened early on in their careers and seek some balance in the form of outside interests, including being more engaged in family life.

Medicine – when practiced within a certain frame of mind – is a field that is almost second to none in its ability to provide satisfaction. But, as in any demanding profession, there are definite trade-offs. “Work-life balance” is just a prettier way to describe it.

*For the record, I am a full-time primary care physician and really do enjoy working as an internist. I have worked no less than 90% of full-time and although no one can predict the future, I intend to continue to work full-time as long as I am emotionally, physically, and psychologically able to provide excellent care. I say this because I once had a glimpse of a place where there was potential harm in working full-time under certain circumstances. And that – rather than a decision by any physician to work part-time – is what is unfair and even dangerous to patients.

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**photo by Renjith Krishnan (freedigitalphots.net)

The Gen Y Physician

photo: Sura Nualpradid, freedigitalphotos.net

Do Gen Y physicians want more by doing less? Are they less dedicated than prior generations? I read an article written by a physician that put this group in a less-than-positive light.

http://www.kevinmd.com/blog/2011/01/millennial-physicians-impact-disease-management.html

I have heard similar observations from a colleague who practices in an academic environment. We often comment on advances in pharmaceuticals, procedures, imaging, and public policy. But there have been cultural shifts in the practice of medicine as well: a move away from paternalism, more collaboration between specialties and teamwork with other physicians, and work-life balance for physicians, for example. While I would agree with some aspects of the aforementioned post, there are a few things to consider.

 The “working to live” trend is not limited to healthcare. This appears to be a common philosophy among the young adults in this country who grew up with parents who labored with one or more jobs or overtime while sacrificing time with family. Perhaps this explains why we see many young, intelligent women choose to stay home rather than work. Or why people work at home rather than in the office.

Other factors have helped to mold the current and up-and-coming generation of healthcare providers who are being criticized in this post. For example, the general public, the media, and the healthcare industry, itself, have minimized the role of the physician. They no longer perceive physicians as “gods” (a title that was unlikely self-described by the members of this profession). When insurance companies that are run by nonmedical administrators dictate the rules of practice and larger physician offices are run by – again – nonmedical administrators that want more productivity, it creates a factory-like environment. Read: hamster on the wheel. Furthermore, the utilization of midlevels (who can earn more per hour than physicians, if you take into account taking call and working on weekends) in the healthcare industry, while quite helpful and valuable, also creates a sense that physicians are potentially dispensable.

There are now more female physicians graduating from medical schools than 10-20 years ago. They typically play many more roles than the role of physician. They often do not have the luxury of staying late at the office  – and, yes, I view it as a luxury – because they may have to pick children up from daycare and make dinner and take care of household duties while husbands stay late at their own jobs. Women have entered into previously male-dominated professions faster than the societal expectations of their roles could practically adjust to take that into account.

Whether we admit it or not, a lack of balance in our lives does translate into our interaction with others. We have often seen or heard of a disgruntled physician interact less than ideally with a patient. As the healthcare industry becomes more customer-service oriented, this would be detrimental. Sometimes finding balance does not align with the Type A expectations of our peers. But I am doubtful that any physician would risk being negligent in order to make it to a soccer game.  

Lastly, I would like to suggest that physicians who are concerned about the work ethic of the next generation of physicians consider being role models or mentors to them, as my friend in academic medicine does. Having a relationships with our peers (regardless of age) is essential for mutual support and can also help younger physicians grow into professionals with excellent work ethics.