It was 8 a.m. on a Tuesday when I found myself sitting, eyes closed, in the conference room of a busy New York City teaching hospital. The instructions were simple, to breathe deep and follow the inflow of air, focusing on the diaphragm as it expanded and relaxed, then release all tension with the out-breath. External distractions such as the tapping of a broken ceiling fan, and internal ones such as worry that my five-alarm pager would go off at any moment, were said to be normal. The purpose of the exercise was to acknowledge these interferences and let them go, focusing on the present moment. Our session ended with each member of the group being asked to say one thing that they do for self-care. As my colleagues went around the room talking about exercise, connecting with loved ones, and being in nature, I was struck by the irony of scheduling a mandatory “wellness” meeting for a group of exhausted infectious disease fellows first thing in the morning.
Workplace wellness is hot right now, with forecasts of a roughly 87.2 billion-dollar global market size by 2027. Physician wellness, in particular, has received more attention over the past few years, with physician burnout at an all time high. Burnout has many potential negative consequences, not only for the physical and emotional health of physicians themselves, but also for patient care — with downstream deleterious effects on the economy related to both. Importantly, physician burnout is not identical across gender lines: the National Academy of Medicine reports a 20-60% higher incidence among women compared to our male counterparts. Undoubtedly, the COVID-19 pandemic has exacerbated this crisis of physician overwhelm, which leads me to wonder: Are physician wellness efforts genuinely substantive — or are they just palliative?
The Lancet describes physician burnout as a “work-related syndrome involving emotional exhaustion, depersonalization and a sense of reduced personal accomplishment.” There are many theories as to the etiology of this global crisis, including increased administrative burden on physicians, cumbersome documentation required by EMRs, less time with patients, and a sense that overwhelming bureaucracy has taken the “me” out of medicine and created a one-size-fits-all model where checklists trump the clinician-patient relationship. The COVID-19 pandemic has piled onto an already strapped system and added an additional element of helplessness and futility as we still struggle to understand the complexities of a rapidly mutating virus and build our evidence base for possible therapeutics when, let’s face it, the best care we currently have is preventative. The roadblocks to physician well-being are clearly structural, so why are our attempts to address them so cosmetic?
Additionally, for women physicians, burnout is exacerbated by gender inequity. The New York Times recently published an article documenting the pay gap between men and women physicians across all fields of medicine, which, the authors hypothesize, has likely widened during the pandemic as women physicians have had to leave the workforce to take on household responsibilities. Women in medicine are shortchanged from the beginning of their careers, which often coincide with childbearing years and no built-in support to protect women physicians’ ability to succeed both personally and professionally. There is no guaranteed paid maternity leave for women physicians.
It is well known that current family leave policies in the U.S. are inadequate compared to those in other developed nations. We are the only Organization for Economic Cooperation and Development country without a national statutory paid maternity, paternity, or parental leave. The Family and Medical Leave Act, enacted in 1993, allows some employees to take up to 12 weeks of unpaid leave; however, only 60% of employees are eligible. Despite this, forward-thinking companies have realized that investing in the health and well-being of employees and families with competitive paid maternity leave policies leads to greater return on investment in terms of employee retention and productivity. The Bill and Melinda Gates Foundation, for example, offers 52 weeks of paid time off for both mothers and fathers in the first year of a child’s life. While this represents the extreme of most businesses in the United States, three months of paid time off is now regarded as the absolute bare minimum for a respectable company.
And yet, the field of medicine, while still held to a high standard of professionalism and respect, lags light-years behind. A nationwide survey of physician mothers published in JAMA in 2019 found that attending and resident physicians take an average of eight and six weeks of paid maternity leave, respectively, most of which is cobbled together from a combination of sick and vacation days. Many of those surveyed are forced to take paid time off to supplement the rest — and are able to do so if, and only if, their department leadership permits it. Most troublingly, the women in the study who took maternity leave reported loss of potential earnings, punishment with increased call schedules when not on leave, less positive peer evaluations, and overall increased maternal discrimination in the workplace. Together, these factors contributed to burnout.
The sad irony of the health care status quo regarding maternity is that it flies directly in the face of what doctors know to be beneficial for both babies and mothers, and of what they suggest to their own patients. The American Association of Pediatrics recommends at least 12 weeks of paid maternity leave, with the 2016 president Dr. Benard Dreyer stating publicly that in an ideal world, mothers would have a minimum of six to nine months leave. His reasoning? The documented benefits on maternal-child bonding, childhood development, and lower rates of maternal depression.
When I think about the wellness initiatives currently offered — and even mandated — by our institutions, I recognize that there are indeed benefits to be found in meditation, nutrition, and a good night’s sleep. However, these strategies are individualistic, not systemic — meaning, they do little to rectify a culture of medicine that expects health care workers, women in particular, to sacrifice ourselves in the name of patient care. In order to fix an archaic system that does not value or protect the many different lived experiences of women physicians, we need much more than “wellness.” Longer maternity leave, wage parity, increased respect for physician mothers, and cognizance that the issues we face are structural would be good places to start.
What policies would you like to see your institution — and the field of medicine in general — implement to help curb burnout? Share your thoughts in the comments below!
Sarah Humphreys is an infectious disease physician who recently joined a private practice affiliated with the Jackson Health System in Miami, Florida.
Illustration by Jennifer Bogartz