On April 12, 2019, ACP held the annual International Forum in Philadelphia on the topic of “Global Experiences and Initiatives to Promote Physician Well-Being.” This was the 13th annual International Forum, which serves as a platform for all internal medicine societies to come together and think about topics of importance to internal medicine specialists and subspecialists.
There was a recognition that across all countries, internal medicine specialists and other physicians are all facing many similar challenges. The day before, the Internal Medicine Meeting 2019 keynote speaker, Vivek Murthy, MD, MBA, had focused on the epidemic of individuals feeling isolated in the world. Much seems to relate to the paradox of technology, which could bring us together, but actually tends to distract us—people are always looking down at screens instead of talking face-to-face with each other. One way to combat the isolation around us is through supporting each other, working together, talking about our challenges, and talking about our patients, our successes, our work, and what we love to do. This is a reason why the International Forum is so wonderful and inspiring because we get to do this with each other on the global level, uniting us together. ACP Officers Ana María López, MD, MACP, President for 2018-2019, and Andrew Dunn, MD, MACP, 2018-2019 Chair of the Board of Regents, in opening remarks focused on the opportunities for collaboration and communication in this Forum.
Mukta Panda, MD, MACP, Forum moderator, started the discussion with a statement: “Healthy physicians are the greatest asset any healthcare system can have.” While being a physician is deeply gratifying, it also comes with stresses and challenges that take a toll on our health and well-being. Physicians in countries across the globe must face this reality. A physician's work is complex and continuously challenging; the combination of mastering the ever-increasing knowledge base of medicine and new clinical skills coupled with the pressures toward efficiency, patient satisfaction, cost-cutting, and electronic medical record use can be exhausting.
As well, physicians can be susceptible to stress and mental health issues yet are reluctant to disclose these due to the perceived stigma and fear of retribution, often times from our own profession, leading us to suffer in loneliness. Therefore, it is not surprising that physician attrition from medical practice is on the rise. The literature on physician well-being is replete with words like “burnout,” “moral injury,” “empathy fatigue,” and “compassion fatigue” to describe the daily lives of physicians. There seems to be a widening gap between a physician's call to heal and the structural demands of the work, pulling us as physicians in different directions. To resolve these tensions, many physicians concentrate their energy on the technical and institutional demands, often sacrificing the more interpersonal and emotional aspects of health care. In this state of being where we feel professionally divided, it can be difficult for us to reconnect and tap into the inner resources of energy and passion.
In the United States, a recent “Charter on Physician Well-being,” published in April 2018, called for a partnership and commitment among individuals of the medical profession and health care organizations to address this epidemic of physician burnout and promote a culture of well-being. It is clear that physicians who are well are best able to serve their patients, students, colleagues, society, and of course profession.
In 2007, the Institute for Healthcare Improvement introduced the Triple Aim, which was to improve clinical quality in patient care and population health and to reduce health care cost. However, it was almost a decade later in 2016 when the rising rates of physician burnout escalated the Triple Aim to the Quadruple Aim, with the addition of a fourth specific aim to include clinician wellness. It is a “joy in medicine” that is found in rich, rewarding relationships with patients, colleagues, and other members of the health care team. It is the reciprocal interplay of practice efficiency, a culture of wellness, and personal resilience that influences the achievement of the Quadruple Aim.
In response, the World Medical Association amended the Declaration of Geneva in October 2017 to include a single statement on the need for physicians to take care of their own health with the same intentionality and devotion that they apply to their patients.
However, we are aware that this issue is not unique to the United States; physicians and researchers around the world are facing the same problem—keeping physicians healthy in a rapidly changing health care environment. What can be done realistically to address these concerns? What would it take to bring the heart and hands of medicine back together in service of healing and care for patients? While the drivers of burnout and lack of well-being may be unique in each of our countries, this issue is germane to us as a physician community. Dr. Panda stated that our community created here today and offered generously by ACP offers a safe and trustworthy space where we can be vulnerable and authentic to have this transparent discussion around this problem. We have an immense opportunity for shared learning and meeting the need for a global collaboration to approach this problem of physician well-being. Collaborating with leaders from around the globe helps us get out of our own space, think more broadly, and explore new ideas.
Following Dr. Panda's introductory remarks, the Forum proceeded with a distinguished panel of physicians representing Australia/New Zealand, Brazil, Canada, the Philippines, and Switzerland.
The panelists were José L. Bonamigo, MD, MBA, FACP, Governor for the Brazil Chapter; Regula Capaul, MD, FACP, then-Co-President of the Swiss Society of General Internal Medicine; Chad Rey V. Carungin, MD, ACP Member, then-President of the Philippine College of Physicians;
Neil E. Gibson, MD, FACP, President of the Canadian Society of Internal Medicine; and Mark Lane, MD, FACP (Hon), President of the Royal Australasian College of Physicians.
Each of them described surveys that have been done in their countries demonstrating psychological distress among medical students, trainees, and doctors in practice. Barriers to physician well-being are workload, the bureaucracy of the workplace, and the frustration with the time spent at work and the time away from family; these are not unique to any single country.
In some situations, stress can be related to the changing nature of practice. Whether it be the significant role that technology now plays or mere changes in location (hospital settings versus ambulatory sites) and workflow, physicians are sometimes finding themselves in work situations that they had not expected earlier in their training years.
There are local issues related to limited resources and simply not enough physicians being available to provide a service. Hence, physicians are pressured both by self and by employers to not take a sick day when needed simply because there is no one to provide backup. Even though physicians know it is not in the interest of their own health to be at work, they feel like they have to. That is both emotionally and physically stressful.
Some of the medical schools in different countries have instituted programs around well-being for medical students as well as faculty, but this does not exist at all in other countries. Yet, in all the countries discussed, including those with well-developed well-being programs, there is a recognition that physicians tend to under-report mental health concerns they might have due to the caregiver culture, the local societal beliefs around mental health, and concerns over possible stigmatization and the impact that might have on the ability to continue to work.
Dr. Gibson noted that the Canadian Society of Internal Medicine (CSIM) has specifically utilized the ACP Physician Well-being and Professional Satisfaction initiative and has trained eight physicians using the ACP Well-being Champions program. CSIM hopes to leverage this initiative and raise awareness, as well as provide some peer support to its members.
It was pointed out that in the U.S., electronic medical records (EMRs) are a tremendous burden experienced by physicians with an expectation of excessive documentation during patient visits. Several physicians from other countries confirmed that EMRs are indeed an issue, but in some cases, there is more standardization and better interoperability.
Several expressed the feeling that much of the EMR software was designed for medical and hospital billing, not for the physicians, nurses, or patients.
Following comments from each of the panelists, the opportunity was provided for members of the international audience to make comments. They expressed that many other countries have very similar issues. Increasing awareness of the burnout and wellness issues among medical colleagues is important, as it seems that many doctors are oblivious to the fact that they are progressively developing burnout.
Robert M. McLean, MD, FACP, President for 2019-2020, raised the question of how much of the problem is the number of hours worked versus the meaningfulness of those hours. He mentioned that he has had numerous conversations with colleagues, some 20 years older, who have said they never felt burnout because even when they were dealing with things in the middle of the night, they felt gratified doing something meaningful for patient care. It may not be the hours and the time, but how they are being perceived and valued. Ideally, physicians who are not overburdened by administrative tasks and whose time is spent meaningfully for patient care can have increased feelings of “higher purpose.” It is not about quantity of time or work, but rather the quality of it.
Douglas M. DeLong, MD, FACP, Chair of the Board of Regents for 2019-2020, commented that this issue has all of the features of a public health crisis, and it should be dealt with as such. There are certain tools and techniques that all of us share, and there are probably public health experts at the Forum. It is an epidemic and it needs to be approached in this way. Dr. DeLong continued by noting a program called Project ECHO. Project ECHO was developed by a gastroenterologist, the only physician in a rural state who took care of patients with hepatitis C. Through electronic means, he helped general internists and family practitioners to become experts in care of patients with hepatitis C. This program has now become widely successful as a means for disseminating knowledge. He commented that ACP may be able to do something like Project ECHO, which is a self-learning, collaborative idea that could be used to educate physicians around well-being.
Dr. Panda noted that if this issue were infectious in nature we would have the Centers for Disease Control and Prevention here actively addressing the problem. If this were a heart issue, we would have the American Heart Association here. As a group, we are poised to claim it, name it, and do something about it.
Darilyn Moyer, MD, FACP, ACP Executive Vice President and Chief Executive Officer, stated that the National Academy of Medicine (NAM) thought this was such a significant problem in the United States that two years ago they started the Action Collaborative on Clinician Well-Being and Resilience. This is a broad stakeholder group. At ACP we have Daisy Smith, MD, FACP, Vice President for Clinical Programs, and Susan Thompson Hingle, MD, MACP, former Chair of the Board of Regents, who represent ACP at this collaborative.
Dr. Moyer continued that just as there was a movement toward quality and patient safety after publication of the “Crossing the Quality Chasm” report by the NAM in 1999, there is finally some momentum and understanding around the importance of these issues. There is a business case that can be made that more professionally satisfied physicians are better for an organization. However, there is also a larger perspective for our health care system and delivery of health care to our patients with impact on all the human elements: patient outcomes, reduction in medical errors, patient engagement, and less clinical workforce turnover. Organizations in other countries should also try to pull stakeholders together, similar to the route that the U.S. is pursuing at the NAM in the hopes that it will lead to significant change.
Nicola Montano, MD, FACP (Hon), President of the European Federation of Internal Medicine, thanked ACP for raising this issue in the Forum. He noted that it seems the landscape is the same around the world. In Europe, there is a constellation of different countries with different incomes and different health care systems, but the problems are still the same. We need healthy physicians. Dr. Montano suggested introducing psychology during medical school to help train our students to take care of themselves over the course of their complex training process. In his division, he introduced a psychology meeting for end-of-life issues, and he saw that his colleagues were very happy and relieved by this. These strategies are important. As the “United Nations” of internal medicine, we should develop an elaborate document about this topic subscribed to and endorsed by all the societies at the Forum. This could help raise public awareness. Patients understand that if their physicians are not healthy, they will be less effective in their delivery of high-quality care.
Dr. Panda mentioned that it is good to align the metrics of well-being to the metrics of larger organizations within which physicians are frequently working. Areas of measurement might include patient satisfaction, physician engagement, retention, rate of physician burnout, and the engagement of the health care team as a whole. Some institutions in the United States have actually started measuring these areas and are attempting to align them with the hospital employers' metrics.
Omar T. Atiq, MD, FACP, Chair of the Board of Governors for 2019-2020, commented that the discussion at the Forum was wonderful. A large issue, especially in the United States, is the cost of medical education. This leads to a tremendous financial burden for young physicians, and that leads them into high-pressure situations encouraging ever-increasing productivity. This can lead to emotional and physical burnout, and so efforts to reduce the burden of debt on the younger physicians can be helpful.
Dr. Panda commented that the financial debt issue raised is very important. Medical schools are talking about introducing financial education and business aspects early on in medical school. She believes that medical school prepares us very well on how to take care of patients and pathology, but there is no “how to live” curriculum. Seasoned physicians should have some sense of how to improve resilience. Dr. Panda has started to create brief interviews with more seasoned physicians about what brings them meaning or joy, and what makes them get up and come to work. She hopes this is contagious with others and will lead to creation of a “how to live” curriculum where there is shared learning. Something that has also been identified in the burnout literature is the loss of purpose from physicians who have been in practice for a long time. Getting these physicians involved in this sort of a project gives them a connection back to that purpose. She has found that it is the “sweet spot” of purpose and passion where meaning and joy are found.
Andrew Goddard, MD, FRCP, FACP (Hon), President of the Royal College of Physicians of London, mentioned that there is a lot of literature looking at what makes people unhappy, but the literature about what makes people happy is relatively small, though it is beginning to grow. He encouraged ACP to start focusing on the positive aspects of medicine and take up the theme of “keeping medicine brilliant.”
Dr. Moyer commented on ACP's ever-developing Physician Well-being and Professional Satisfaction website. This is a major initiative of the College. In fact, ACP just trained 60 more Well-being Champions for our domestic and international chapters. Only a handful of our 89 chapters do not have someone trained in these skills. She continued that on that webpage are a large number of resources that are all very much about the positive and the solution; this is not just reacting to a problem.
Dr. McLean noted that the comment “keeping medicine brilliant” is where Dr. DeLong and he want to go with this. In addition, as part of the Physician Well-being and Professional Satisfaction initiative, ACP has a well-being taskforce in addition to the Well-being Champions. ACP and Jack Ende, MD, MACP, a Past President, are also working on a Master Clinician Task Force. This is an idea around what can be done to energize our internist colleagues as they progress through their careers, learning what they can do to become the “master clinician” they aspire to. This potentially positive force is still in the process of being framed. As this is being sorted out there is clearly a consensus that this is an international problem. The idea about framing this positively is important. Dr. McLean commented that he thinks the idea of having some sort of consensus statement document is excellent. This is in fact a public health crisis.
Dr. McLean urged attendees to join the International Forum online discussion group. Contributions to this online forum are important, especially as we look at truly having an action item of generating a document onto which various organizations can sign. To do this, explicit input from people is needed. One of the lessons of the Forum is how absolutely common so many of these themes on well-being are across all of our countries.
Dr. Panda concluded the Forum by recognizing the bigger community present. She also thanked the panelists and attendees for all their contributions during the discussion. ACP promises to keep moving this work forward. Last, she commented about the need for us to effectively speak about physician well-being to others—developing our “elevator speech” to convey the need, importance, and urgency for addressing physician well-being issues. She again thanked everyone for making their voices heard at the Forum. All comments were very important and very helpful.
ACP International Forum Panelists:
- Mukta Panda, MD, MACP, Moderator
- José L. Bonamigo, MD, MBA, FACP, Governor, ACP Brazil Chapter
- Regula Capaul, MD, FACP, Co-President, Swiss Society of General Internal Medicine
- Chad Rey V. Carungin, MD, ACP Member, President, Philippine College of Physicians
- Neil E. Gibson, MD, FACP, President, Canadian Society of Internal Medicine
- Mark Lane, MD, FACP (Hon), President, Royal Australasian College of Physicians
- ACP International Forum Participants:
Ana María López, MD, MPH, MACP, President
Andrew Dunn, MD, MPH, MACP, Chair, Board of Regents
Robert M. McLean, MD, FACP, President-elect
Douglas M. DeLong, MD, FACP, Chair-elect, Board of Regents
Jack Ende, MD, MACP, Immediate Past President
Robert H. Lohr, MD, MACP, Treasurer
Gregory C. Kane, MD, MACP, Treasurer-elect
Darilyn V. Moyer, MD, FACP, Executive Vice President, Chief Executive Officer
George M. Abraham, MD, MPH, FACP, Chair, Board of Governors
Omar T. Atiq, MD, FACP, Chair-elect, Board of Governors
Jacqueline Winfield Fincher, MD, MACP, President-elect Designee
Heather E. Gantzer, MD, FACP, Chair-elect Designee, Board of Regents
William E. Fox, MD, FACP, Chair-elect Designee, Board of Governors
Internal Medicine Society Representatives
João Araújo Correia, MD, FACP (Hon), President, Portuguese Society of Internal Medicine
Nuvia Batista Rujano, MD, FACP, President, Panamanian Society of Internal Medicine
M. Ian Bowmer, MD CM, FACP (Hon), President, Royal College of Physicians and Surgeons of Canada
Virgil Carballo Zarate, MD, FACP, President, Colombian Association of Internal Medicine
Ding-Cheng (Derrick) Chan, MD, FACP, Deputy Secretary General, Taiwan Society of Internal Medicine
Chan Choong Meng, MD, FACP (Hon), President, College of Physicians, Singapore
Maritza de Jesus Durán Castillo, MD, FACP, President, Venezuelan Society of Internal Medicine
Evert-Jan F.M. de Kruijf, MD, FACP (Hon), President, Dutch Society of Internal Medicine
Somchai Eiam-Ong, MD, FACP, President, Royal College of Physicians of Thailand
Alba Celeste Frías Sosa, MD, President, Dominican Republic Society of Internal Medicine
Andrew Goddard, MD, FACP (Hon), President, Royal College of Physicians of London
Ricardo Gómez Huelgas, MD, FACP (Hon), President, Spanish Society of Internal Medicine
Roxanna Hiza Ribera, MD, FACP (Hon), President, College of Internal Medicine of Bolivia
Sonia Indacochea Cáceda, MD, President, Peruvian Society of Internal Medicine
Thilak Jayalath, MD, FACP, President-elect, Sri Lankan Society of Internal Medicine
Hans-Peter Kohler, MD, MACP, Secretary General, International Society of Internal Medicine
Johanna Adriana (Adri) Kok, MD, FACP, President, Faculty of Consulting Physicians of South Africa & President, International Society of Internal Medicine
Patrick Lacor, MD, FACP, Vice President, Belgian Society of Internal Medicine
Luz María Letelier, MD, FACP, Past Secretary General, Chilean Society of Internal Medicine
Roberto López Espinosa, MD, FACP, President, Mexican College of Internal Medicine
Nicola Montano, MD, FACP (Hon), President, European Federation of Internal Medicine
B.A. Muruganathan, MD, FACP, Governor, ACP India Chapter, Past President, Association of Physicians of India
Sally Aman Nasution, MD, FACP, President, Indonesian Society of Internal Medicine
Antonello Pietrangelo, MD, FACP (Hon), President, Italian Society of Internal Medicine
María Salomé Pilheu, MD, FACP, President, Buenos Aires Society of Internal Medicine
Estela Maria Torres de Taboada, MD, President, Paraguayan Society of Internal of Internal Medicine
Chow Yu-fat, MD, Honorary Treasurer, Hong Kong Academy of Medicine