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
ReviewPhysician wellness: a missing quality indicator
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
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