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Rebuilding the Social Contract 3
The second of the five “A’s” of traditional practice is affability, which older physicians believed was more important than ability. What did they mean? They were thinking of affability as a virtue which embodies the quality of being friendly and approachable in both behavior and language toward others. Often called "the friendliness of daily life"; it balances being too agreeable with being argumentative. (Thomas Aquinas)It is considered a form of justice and charity, recognizing the dignity of others through kindness. The elders, then, were not suggesting “putting on a happy face,” particularly when dealing with serious issues, but were warning the newly trained physician about the danger of hubris. They knew new physicians are often convinced they know the right answer to just about everything. The more experienced clinician, though, knew the truth of the adage: “It’s more important to know the patient who has the disease than to know the disease the patient has.” The current version of this trap is “knowing the guidelines.” As we have discussed, the guideline development process is designed to be a systematic assessment of the literature, but should be thought of as a dynamic process always subject to revision. This latter point is often overlooked, particularly in an era when performance measurement is increasingly prevalent. The new physician may view the current guideline as stone tablets handed down on the mountain, but the experienced physician will be more skeptical. But since money is attached to compliance with the guidelines, we will probably get more organized bad results than the random bad results when everybody does their own thing. The other aspect of affability is best thought of as an institutional issue. When I was looking at jobs many years ago, I noted that the halls of academic institutions were crowded, but most of the people were tense and stressed—and certainly not affable. When I toured the halls of private institutions, though, people were visibly more relaxed, and seemed to be enjoying their work, and were generally affable. Nowadays, though, I find very few hospitals where the staff are not tense and stressed. I attribute this negative change to one thing primarily: excessive workload, or perhaps a better term: “toxic volume.” This is a direct result of the need to have more “though put” for institutional prosperity without a concomitant increase in the resources necessary to do this. As an example, early in my career, rounding on 10 patients per weekend day seemed to be a good load, but my partners who are still in practice expect to round on 60-70 per day. No matter how efficient they are, this puts a strain on everyone, including nursing staff, and leads to burnout, turnover, and a downward spiral in safety and quality cultures that make carrying these loads ever more burdensome. Needless to say, being glad to see a new patient is rare, and faking it is not a strategy for success. Our systems are not affable. Recently, a study was published looking closely at physician attrition. 1 In a summary, the authors noted: 2 “The overall point of this study, or one of the big takeaways, was that rates of physician attrition increased from 3.5% in 2013 to 4.9% in 2019, but we also looked 1 Rothstein LS, He Z, Dzuria J, et. al. Ann Intern Med 2025;178(12):1698-1708. doi.10.7326/annals-25-00564. 2 https://www.acpjournals.org/doi/10.7326/acpi-20260113-unpacking-physician-attrition at changes in rates of attrition by group. One of the things that not sure I expected but is important to note is that attrition rates increased across almost all of the groups we looked at over the study period. They increased for both male and female physicians in both rural and urban settings, across specialties, across geographic regions, and across all age groups of physicians 35 and up. One could hypothesize, and we do show in our models, that certain physician factors were associated with a higher likelihood of attrition in general, but it was notable that the increase in rates of attrition happened across all of these groups…Given that we are seeing increases [in attrition] across different categories of physician sex, physician location, physician specialty, it means that there won't be a one-size-fits-all answer. We probably need to do a deep dive into each of those scenarios. There are likely some common factors, an increased burden of asynchronous work, increased expectations from patients and colleagues, that are driving these trends, but there are likely specific drivers within each of the subcategories. What makes work less sustainable for a hospital-based physician is probably not completely the same as what it is for an OB-GYN physician or primary care physician…To me, the takeaway is that more clinicians are leaving practice, but our patients still need us. To reverse this trend, we as clinicians have an opportunity to think about what it takes to make our practice more sustainable so that we are providing the care that our nation needs. We have an opportunity to inform our health systems and our leaders about what changes would make a difference to us and reverse the attrition trend our article demonstrated, whether it's patient panel expectations, whether it's team-based supports, whether it's the overall practice environment.” Maybe we could start by developing an affability quotient for each unit in a medical organization, be it a ward, a clinic, or a group of like specialists. As I reflect on the times when my affability quotient dipped, I can identify several themes. First, it was not long hours or stressful decisions so much as it was the pressure of trying to get this patient tended to so I could get to the next one (or more) who were already queued up and waiting. What I needed, but did not have, was a way to say “enough for now—someone else needs to do the next patient.” Secondly, there were times when things were stressful in my personal life that reduced my affability. Again, there was no practical way to slow work responsibilities to account for temporary stressors outside of work. Since more physicians are committed to work/life balance, and is one of the factors they consider in choosing a job, perhaps this is something medical organizations can create—a way to depressurize the demands of toxic volume. Who knows, burnout and turnover might decrease, and the safety and quality cultures might improve—a virtuous cycle to replace the current toxic cycle. |
Further Reading
Addressing Health Care Culture A contrary view of the culture changes needed in healthcare. Advisory Report on Burnout, part 1 Health care worker burnout has become so prevalent, the US Surgeon General has issued an Advisory Report on immediate steps needed. Bandwidth Bandwidth, the mental and emotional capacity to handle information flow, is routinely ignored in healthcare. We need to rethink when, and for what, we really need the overloaded clinician's attention. Getting the Tempo Right Effective doctor and patient communication requires getting the tempo of the conversation, not speed, but the current production system makes this a rare event. Necessary Conversations Conversation is an essential step if we are to overcome the problems with our current dysfunctional health care system. Nursing Staff Turnover If empowered teams of clinicians is the key to effective, efficient care, then staff turnover is Achilles' heel. Nationally, RN turnover exceeds the cap needed to maintain patient safety and quality of care. The problem and approaches to a solution are considered. |