Physician Work Environment and Well-being: A Call for Papers.

In themiddle of the last century, the profession of medicine consolidated its identity firmly around an ideal: physicians were expected to be dedicated to thewelfare of their patients above all other considerations, committed to thepublicgood,and impervious to financial temptation or other self-interest. The insular training and longworkhours that set theprofessionapart frommostpeoples' experience further cemented this special identity. The past should not be unduly romanticized. Yet the professional ideal held a commanding presence, even when honored in the breach. Physicians enjoyed tremendous respect and trust from thepublic, andwere grantednear-completeautonomyanddiscretion in theirwork. By and large, they were delighted with their profession. Certainly, some physicians still feel the aura of a deep professionalcontentment thatwasmorecommoninearlier,more idealistic times. Today,medicinehasmorepower tohelppeople than ithas ever had. We can be proud of transformative diagnostic and therapeutic advances, as well as large strides away from the elitism and prejudice that characterized some of our predecessors.Yet, althoughsomeargue thatoverall satisfactionwith career choice has stayed roughly stable,1 more probing study suggestsanacceleratingdiscontent.Therateofburnoutamong Americanphysicians increased from45%to54%just from2011 to 2014,2,3 and half of residents leave their training already burned out.4 Some physicians believe that medicine is in decline, and would not choose medicine again, or recommend the profession to their children. The extent to which this attitude exists has not been well quantified through empirical studies, but may be substantial. Whathappened tosochange themedicalprofession?A lot. In most readers' lifetimes, we have seen large changes in the practice environment, including the emergence of prospective and value-based payment systems, a rapid shift from independent small practice to employment by large medical groups and hospitals, increasing specialization, the growing role of nonphysician clinicians, the expanding presence of chronic disease and intensive care, a proliferation of quality measures, and burgeoning regulation and scrutiny by payers. Many of these changes have stemmed from efforts to advance thequalityofpatient care,butnonethelesshavebrought new frustrations for clinicians, such as increasing administrative complexity, large requirements for documentation, and thewidespreaddeploymentof electronicmedical records that are not easy to use. Academic physicians face special challenges including increasing competition for research funding and the need to adapt to resident work hour limitations. Regardless of the value of some of these changes, in aggregate they represent an overhaul of the practice environment. Havewepaidenoughattention tohowthese changeshave affected physicians? In this issue of JAMA Internal Medicine is a review andmeta-analysis by Panagioti and colleagues5 of interventions to reduce burnout in physicians. The findings are similar to those of another recently published metaanalysis by West and colleagues.6 Both studies demonstrate small but significant reductions in burnout,withwidely varying interventions. Consistent with the hypothesis about the importance of challenges in the practice environment, Panagioti et al5 found that organizational changes—including to physicians’ workload and schedule, evaluation and supervision, and job control—weremore effective in reducingburnout than interventions targeted to improving physicians’ personal coping strategies. They note, however, that the organizational initiatives studiedwere rare andmost often limited in scope, possibly becauseof the costs of delivering them. From a practical standpoint, it is likely that health care organizationscanaccomplishonly somuch in trying to reducephysician burnout, within the context of the broader and sweeping changes in clinical practice. Given the sea changes inhealth care,what is perhapsmost surprising is that somany traditions and characteristics of the medical profession have endured. But, closely related to changes inphysicians’well-being, the cohesive identity of the professionhas frayed.Althoughphysiciansareexpected toput advocacy for their patients above all other interests, they are now also increasingly asked to serve as stewards of costs.7,8 These goals often, but not always, align. Where many physicians once rejected commercialism,manynowhave relationshipswith industry,9 andbyand largeaccept the idea that they can be “incentivized” to alter the care they provide by payfor-performance programs. Where physicians once worked hours based primarily on the needs of their patients, they are increasingly in shift arrangements or, in the case of training, restricted in their work hours. Where physicians once cared for patients autonomously, they are now subject to oversight by employers and payers, and asked to follow standardized protocols.10 Although physicians were once unique, they now provide care side-by-side in teams, or in some cases in Related article Opinion