Elsevier

The Lancet

Volume 374, Issue 9702, 14–20 November 2009, Pages 1714-1721
The Lancet

Review
Physician wellness: a missing quality indicator

https://doi.org/10.1016/S0140-6736(09)61424-0Get rights and content

Summary

When physicians are unwell, the performance of health-care systems can be suboptimum. Physician wellness might not only benefit 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.

Introduction

“Healthy citizens are the greatest asset any country can have.”

Sir Winston Churchill

Physicians are important citizens of health-care systems, and evidence indicates that many physicians are unwell. Physicians who are affected by the stresses of their work may go on to experience substance abuse, relationship troubles, depression, or even death.1, 2, 3, 4 Results of emerging research show that physicians' stress, fatigue, burnout, depression, or general psychological distress negatively affects health-care systems and patient care.5, 6, 7, 8, 9, 10, 11, 12 Thus when physicians are unwell, the performance of the health-care system can be suboptimum. The corollary is that physician wellness might not only benefit 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.”

Traditionally, health-care organisations assess 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 difficult to revoke because of individual, professional, 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 affects 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.

Section snippets

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% 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

Suboptimum attention to self-wellness by physicians

Physician wellness is complex and multifaceted: individual, professional, and organisational factors might affect 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, 53, 54, 55 Arnetz20 refers to the “ignorance, indifference and carelessness of physicians towards their own health”; physicians neglect to have physical examinations and procrastinate when

Unwell physicians negatively affect health-care systems

Growing evidence points to important negative consequences of physician ill health to health-care systems by affecting recruitment and retention of physicians, workplace productivity and efficiency, 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 school training is extremely stressful and often has negative effects on

Physician wellness as an indicator of health-system quality

In view of the effect of suboptimum physician wellness on health systems, measurement of provider wellness as a health-system quality indicator could be highly beneficial. For effective 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 intervene if suboptimum system performance is

Conclusion

The first 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

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

References (100)

  • JE Wallace et al.

    On physician well being-you'll get by with a little help from your friends

    Soc Sci Med

    (2007)
  • NJ Farber et al.

    Physicians' willingness to report impaired colleagues

    Soc Sci Med

    (2005)
  • LW Roberts et al.

    Medical student illness and impairment: a vignette-based survey study involving 955 students at 9 medical schools

    Compr Psychiatry

    (2005)
  • PJ Baldwin et al.

    Young doctors' health—II. Health and health behavior

    Soc Sci Med

    (1997)
  • M Linzer et al.

    Predicting and preventing physician burnout: results from the United States and Netherlands

    Am J Med

    (2001)
  • BB Arnetz

    Subjective indicators as a gauge for improving organizational well being: an attempt to apply the cognitive activation theory to organizations

    Psychoneuroendocrinology

    (2005)
  • MC Sargent et al.

    Stress and coping among orthopaedic surgery residents and faculty

    J Bone Joint Surg Am

    (2004)
  • J Firth-Cozens

    Individual and organizational predictors of depression in general practitioners

    Br J Gen Pract

    (1998)
  • E Frank et al.

    Self-reported depression and suicide attempts among U.S. women physicians

    Am J Psychiatry

    (1999)
  • J Graham et al.

    How hospital consultants cope with stress at work: implications for their mental health

    Stress Health

    (2001)
  • TD Shanafelt et al.

    Relationship between increased personal well-being and enhanced empathy among internal medicine residents

    J Gen Intern Med

    (2005)
  • TD Shanafelt et al.

    Burnout and self-reported patient care in an internal medicine residency program

    Ann Intern Med

    (2002)
  • ES Williams et al.

    Outcomes of physician job satisfaction: a narrative review, implications and directions for future research

    Health Care Manage Rev

    (2003)
  • AM Fahrenkopf et al.

    Rates of medication errors among depressed and burnt out residents: prospective cohort study

    BMJ

    (2008)
  • CP Landrigan et al.

    Effect of reducing interns' work hours on serious medical errors in intensive care units

    N Engl J Med

    (2004)
  • SW Lockley et al.

    Effect of reducing interns' weekly work hours on sleep and attentional failures

    N Engl J Med

    (2004)
  • CP West et al.

    Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study

    JAMA

    (2006)
  • EL Weiner et al.

    A qualitative study of physicians' own wellness-promotion practices

    West J Med

    (2001)
  • TD Shanafelt et al.

    The well being of physicians

    Am Med J

    (2003)
  • Pathways to quality health care. Performance measurement: accelerating improvement

    (2006)
  • Guide to physician health and well being: facts, advice and resources for Canadian doctors

    (2003)
  • ES Williams et al.

    Heavy physician workloads: impact on physician attitudes and outcomes

    Health Serv Manage Res

    (2007)
  • NT Ayas et al.

    Extended work duration and the risk of self-reported percutaneous injuries in interns

    JAMA

    (2006)
  • LK Barger et al.

    Extended work shifts and the risk of motor vehicle crashes among interns

    N Engl J Med

    (2005)
  • JE McMurray et al.

    Physician job satisfaction: developing a model using qualitative data

    J Gen Intern Med

    (1997)
  • K Umehara et al.

    Association of work-related factors with psychosocial job stressors and psychosomatic symptoms among Japanese pediatricians

    J Occup Health

    (2007)
  • TD Shanafelt et al.

    The well being and personal wellness promotion strategies of medical oncologists in the North Central Cancer Treatment Group

    Oncology

    (2005)
  • C Goehring et al.

    Psychosocial and professional characteristics of burnout in Swiss primary care practitioners: a cross-sectional survey

    Swiss Med Wkly

    (2005)
  • BE Landon et al.

    Changes in career satisfaction among primary care and specialist physicians, 1997–2001

    JAMA

    (2003)
  • CA Franke et al.

    Improving anticoagulation therapy using point-of-care testing and a standardized protocol

    Ann Fam Med

    (2008)
  • C O'Connor et al.

    Medical admission order sets to improve deep vein thrombosis prophylaxis rates and other outcomes

    J Hosp Med

    (2009)
  • T Hoff et al.

    Thriving and surviving in a new medical career: the case of the hospitalist physicians

    J Health Soc Behav

    (2002)
  • J Sundquist et al.

    High demand, low control, and impaired general health: working conditions in a sample of Swedish general practitioners

    Scand J Public Health

    (2008)
  • MG Warren et al.

    Physician satisfaction in a changing health care environment: the impact of challenges to professional autonomy, authority, and dominance

    J Health Soc Behav

    (1998)
  • TJ Hoff

    The physician as worker: what it means and why now?

    Health Care Manag Rev

    (2001)
  • J Henry

    OMA membership survey results confirm overwhelming level of frustration among Ontario physicians

    Ont Med Rev

    (2004)
  • JS Cohen et al.

    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)
  • C Renzi et al.

    Burnout and job satisfaction comparing healthcare staff of a dermatological hospital and a general hospital

    J Eur Acad Dermatol Venereol

    (2005)
  • L Goitein et al.

    The effects of work-hour limitations on resident well being, patient care, and education in an internal medicine residency program

    Arch Intern Med

    (2005)
  • LN Dyrbye et al.

    Burnout and suicidal ideation among U.S. medical students

    Ann Intern Med

    (2008)
  • Cited by (1136)

    View all citing articles on Scopus
    View full text