The Merriam-Webster dictionary defines value as “the regard that something is held to deserve; the importance, worth, or usefulness of something” and “relative worth, utility, or importance.” We usually assess our professional worth by how we are treated at work. In social valuing framework, we are given social status based on how others regard us for who we are, what we do, and what we are worth. This is described as “felt worth,” which encapsulates our feelings about how we are regarded by others, in contrast to self-esteem, which is more of an internally held belief.
Our power came from our relationship with our patients and our ability to communicate and influence our patients, peers and administrators. As owners of our practices and small businesses, our currency with hospitals and lawmakers was our ability to bring revenue to hospitals and patient concerns directly to legislators. Practicing in more than one hospital made us more valuable and hospitals battled with each other to provide us and our patients the latest tools and conveniences. In return, we gave our valuable time freely without compensation to hospitals as committee members, task force members, and sounding boards for the betterment of the community. If I were a conspiracy theorist, which I am not, and wanted to devalue physicians I would seek to weaken the physician-patient bond. The way to implement this would be for a single hospital employer to put us on a treadmill chasing work relative value units, give us hard-to-accomplish goals, and keep moving the goalpost. Like I said, I do not believe in conspiracies.
The tsunami of byzantine regulations, Stark laws, and complicated reimbursement formulas has sapped our energy to counter the devaluation. Some are glad to see physicians, particularly surgeons, get their comeuppance because we are perceived as having large egos. This may be true in some instances. Yet, it turns out that the top three job titles with the largest egos are: private household cooks, chief executives, and farm and ranch managers.1
Physicians are also reputed to be possessing dominant leadership styles and seen as bossy and disruptive. Hence, we are made to have frequent training in how to ameliorate our disruptive behavior tendencies. Again, this may be true in a few cases. However, while reports mention how many people witness such unacceptable behavior, there is no valid data about the incidence in practicing physicians. Research also does not support the view that physicians have dominant and aggressive personalities leading to such behavior.
One of the leading interpersonal skills model is Social Styles. We happen to teach this to our faculty at the Ohio State Medical Center’s Faculty Leadership Institute. Turns out that physicians and nurses are almost equally placed into the four quadrants of leadership styles: driving, expressive, amiable, and analytical. I found similar findings in our society members participating in a leadership session I moderated. Indeed, we rank very high on “versatility,” a measure that enables us to adapt our behaviors to fit with our patients and coworkers.
Reported burnout rates of 50% in physicians may or may not be accurate, but burnout is real and so is depression and so are physician suicides. I have witnessed six physician suicides in my career thus far. Teaching resilience, celebrating doctor’s day, and giving out a few awards are all interventions after the fact. Preventive measures like employers and hospitals prioritizing removing daily obstacles eliminating meaningless work, providing more resources to deal with EMRs, and making our lives easier at work, so we can get to our loved ones sooner would help.
Physicians have been largely excluded themselves from participating in the health care debate. We want to see empirical evidence before we sign on to every new proposed care model. Otherwise, we cling on to the status quo and therefore, decision makers tend to leave us out. More important, value-based payment models have not thus far led to reduction in the cost of health care. Despite poor engagement scores at major health systems, physicians are “managed” and sidelined, and mandates are “done to them, not with them.”
In my 40-year career, our devaluation has been a slow and painful process. It started with being called a “provider.” This devalues me. Call me by what I am and do. Physician. Doctor. That is what our patients call us. But, we have been pushed to acquiesce. So, why do physicians undervalue themselves and are unable to be confident of their value to employers and hospital executives?
Some have theorized that physicians have low self-esteem and that denial and rationalization are simply defense mechanisms. The low self-esteem is traced back to medical student days and considered “posttraumatic” disorder. In one study of 189 medical students, 50% reported a decrease in their self-esteem/confidence. The students blamed their residents and attendings for this reaction. Some degree of intimidation may continue into training and employment where it may be part of the culture. We need to change this cycle and treat our students, residents, and mentees with respect as future peers.
Another aspect is related to our own well-being. Most physicians value their patient’s health more than their own. That concept is drilled into us throughout our life. Our spouses complain that we care more about our patients than we do for our families. We often ignore warning signs of serious issues in our own health, always downplaying textbook symptoms of burnout, depression, and even MI. Being too busy is a badge of honor to indicate how successful and wanted we are. This also needs to change.
Sheryl Sandberg in her book “Lean in” discusses the “tiara syndrome,” mainly referring to women. I would suggest that this applies to a lot of physicians, both men and women. Physicians tend to keep their heads down, work hard, and expect someone to come compliment them and place a “tiara” over their head. We may be wary of being called “self-promoters.” Sometimes it is cultural baggage for immigrant physicians who are taught to not brag about their accomplishments. It may behoove us to judiciously make peers and leadership aware of our positive activities in and outside the health system.
Some see physicians not as “pillars of any community,” but as “technicians on an assembly line” or “pawns in a money-making game for hospital administrators.” This degree of pessimism among physicians in surveys is well known but there is good news.
In a 2016 survey based upon responses by 17,236 physicians, 63% were pessimistic or very pessimistic about the medical profession, down from 77% in 2012.2 In another poll, medical doctors were rated as having very high or high ratings of honesty and ethical standards by 65%, higher than all except nurses, military officers, and grade school teachers.3 When the health care debate was at its peak in 2009, a public poll on who they trusted to recommend the right thing for reforming the healthcare system placed physicians at the very top (73%)ahead of health care professors, researchers, hospitals, the President, and politicians. Gallup surveyed 7,000 physicians about engagement in four hierarchical levels: Confidence, Integrity, Pride and Passion. Physicians scored highly on the Pride items in the survey (feel proud to work and being treated with respect).4 In other words, if we are treated well, we feel proud to tell others where we work.
Finally, like many I may consider myself an expert in all sorts of things not relevant to practicing medicine. Yet, I respectfully suggest we stay away from political hot potatoes like nuclear disarmament, gun control, climate change, immigration, and other controversial issues because they distract us from our primary mission. I would hate to see us viewed like Hollywood.
Bhagwan Satiani, MD, MBA, is professor of clinical surgery in the division of vascular diseases and surgery at Ohio State University, Columbus. He blogs at www.savvy-medicine.com . Reach him on Twitter @savvycutter.