“We need to experience fairness and respect, and we need to see that our individual values align with the values of our organizations, and of our health care system as a whole,” says Colin P. West, MD, PhD.
In this installment of “Begin Your Journey,” Colin P. West, MD, PhD, talks with host Scott A. MacDiarmid, MD, FRCPSC, about the concepts of physician personality and pathologic altruism, as well as the “MVPs” of wellbeing. West is a professor of biostatistics, medical education, and medicine at Mayo Clinic in Rochester, Minnesota. MacDiarmid is a urologist with Alliance Urology Specialists in Greensboro, North Carolina.
MacDiarmid: Please talk about the concepts of physician personality and pathologic altruism.
West: These are really interesting concepts, and the physician personality has been written about for decades. Glen Gabbard [, MD], wrote about this and published a paper in JAMA in 1985. That's how far back this goes. Physicians are recognized to have this compulsivity triad. And what's involved there are feelings of doubt and uncertainty about our decisions. We're always wondering, is this the right thing to do for our patients? When things don't go the way we want them to, we feel guilty about it. And we have an exaggerated sense of responsibility. And for any listeners out there, if you think none of that applies to you, I suggest you talk to a friend, a loved one, a spouse, a partner, and they're going to set you straight. And that's true in all walks of medicine. But I would posit that that sense of responsibility, that sense of ownership, when you have a direct physical impact on patients—think about surgeons, for example: operating, breaking the skin—there's something about that sense of responsibility that is adaptive. It's part of your dutifulness, your obligation to your patients to be providing the care to them, as the person who keeps them safe. There are adaptive components to that. But it can be maladaptive as well, because we are really poor at setting boundaries around that. And that's where this concept of pathological altruism comes into play. This phrase was coined by Barbara Oakley [, PhD]. It's this idea that if you take your altruistic tendencies to an extreme, you can actually exhaust yourself; you give so much of yourself that you are actually less able to take care of your patients in a safe, effective way. And again, as individuals, we're not very good at knowing our limits. Duty hours is a great example. Very few physicians acknowledged in the early days of duty hour regulation, that when they were working 110 hours a week, they might be impaired in any way, despite there being ample sleep literature to suggest that being up for 24 hours straight provides cognitive performance deficit roughly equivalent to a blood alcohol level of .08. So the idea that somehow physicians aren't subject to those same physiological limitations doesn't make a ton of sense. So we need to have systems in place to, in some respects, save us from ourselves, and to allow us that time, that space to restore, to recharge our batteries, so that we can bring our altruistic tendencies back in a way that is not pathologic, that actually serves its intended purpose on behalf of our patients.
MacDiarmid: I've never asked myself this question. If you had to say, Colin, what are the top 3 or4 reasons you think doctors and or surgeons are burned out? It's a very complicated question, but are there a few [key factors]?
West: It's a great question, and it's difficult for the reasons that you identified. Part of it is because there are multiple recognized categories of drivers of burnout. And what is most prominent for an individual differs from person to person. So I'm going to answer the question traditionally, and I'm going to give you my 30,000-foot view that I think encompasses all of it. So I am going to give you my 1 takeaway as the main overarching driver, in my view, having already acknowledged that that is going to be simplistic. Christina Maslach [, PhD] and others have written about common drivers. We know that excessive workload is a contributor. Physicians are used to working hard; we're not talking about 40 hours vs 45 hours a week, we're talking about the difference between 60 and 80 hours a week that many physicians are putting in, where we start to slide down a curve that leads us more toward distress, and away from feeling like we're flourishing. [Another factor is] having a sense of control or autonomy in your work. We're not widgets who are managed; we are making independent decisions, and in our work days, we need to feel that that's being honored. Intrinsic reward shouldn't be a big deal in medicine, because the work we do is intrinsically rewarding. Extrinsic reward does matter, and so we need to be compensated fairly for the work and the training that we do. Medicine is a team sport, so we need to have community connection and increasingly understanding this term belonging, which also starts to connect us across other professionals, starts to link to concepts of equity, inclusion, and diversity in really important ways. We need to experience fairness and respect, and we need to see that our individual values align with the values of our organizations, and of our health care system as a whole. Those are common main drivers, and you can zero in on where the electronic medical record contribute or detract from multiple of those. But my simplistic distillation of all of this is that I like to talk about the MVPs of wellbeing, and what I mean by the MVPs is meaning, values, and purpose. If we honor and promote meaning, values, and purpose in our careers, we will connect with what helps set us up for engagement and wellbeing. When people struggle in their medical careers, a common pathway for almost everyone I've ever encountered on that side of things is that they've experienced barriers or disconnection from meaning, values, and purpose in their work as a physician, and when they are separated from those MVPs, that sets them up for the other concepts that we hear about when we think about distress—things like moral injury. "I know what I should do, but the system doesn't allow me to and my patients aren't getting what they deserve. Now I feel internally wounded by that." Burnout is part of this, fatigue is part of this, interpersonal stress is part of this, but those MVPs are a common pathway that I think all of these commonly discussed drivers of burnout that are more granular run through.
This transcription has been edited for clarity.