The Kingdom of Bhutan measures their national wealth in terms of GNH: Gross National Happiness, rather than money. They have done this since 1971, rejecting the standard reporting metric of GDP, Gross Domestic Product.
Each year they survey citizens for happiness and compare it to prior years to judge progress. In 2015 (results below) ~43% of Bhutan’s people reported that they were “Deeply or Extensively Happy”. I am told that in Bhutan they do not have speed limits-rather they have signs saying, “Life is a journey! Complete it!). The people of Bhutan are not only becoming happier, they appear to be becoming healthier. Their life expectancy has doubled in the past 2 decades.
While I admit the GNH is a qualitative and subjective metric, so too is happiness (I am happy because…I believe I am happy). I also acknowledge that the analogy to Bhutan is imperfect.
This blog is inspired by the desire to have a conversation about how happy our faculty members are and to optimize their wellness. I worry about physician wellness because, while physicians are well paid, they work hard, put in long hours, deal with many stressors. This concern made me wonder about our own GNH and raised the notion of doing a quick check on happiness with life in the Department of Medicine.
So, in light of these stressors, despite with some trepidation, I took the opportunity to survey the faculty members at a recent retreat held by the Department of Medicine at Queen’s University. The retreat was attended by ~90 faculty members of our Department (~90%) and the survey (a paper based anonymous poll) was administered during the course of the evening. The survey response rate was ~45%. The Departmental administrative team analyzed results. Before I give you the unedited survey results let me expand a bit on my concern about physician happiness and the motivation for my survey (and no I am not trying to compete with the King of Bhutan).
Spoiler alert-the survey results were reasonably positive. This raises the possibility that by releasing the results I will appear to be smug or to have discounted the voice of faculty members who are not content with the status quo. This is not my intent; but once a survey of satisfaction is performed it must be released. When organizations fail to release such results it conveys volumes about what is being hidden. I hope you will read on and believe that the purpose of the survey and the blog is to be open about the challenges we face and the response physicians have to the complex and rapidly evolving practice environment we face in Ontario in 2015.
Let’s briefly review some of the stressors in the professional life of a physician in Ontario in 2015. Young people aspire to be physicians in ever increasing numbers. Queen’s University’s Medical school receives 5000 applications/year for 100 spots. The medical profession has many virtues. The profession offers a relatively unique chance for self-fulfillment. A career in medicine offers the chance to make a positive difference in the world each day. Medicine is a relatively stable career with little threat of unemployment. Moreover, physicians tend to be respected by others in society. Despite these virtues, and financial rewards, Medicine is seen (even by some medical students) as demanding, stressful and a career that may compromise one’s personal life style and thus reduce happiness. Indeed, our medical students at times feel they are “burning out” and yet their candle has just been lit. This led the leadership of our Medical school to hold an interesting symposium on being resilient and maintaining Aequanamitas (the subject of a prior blog).
After medical school physicians face stress as they deliver patient care. Of course, physicians face the stress of caring for patients who are ill or dying. These stresses range from diagnostic uncertainty and the fear of making errors or causing harm to the frustrations of navigating patients through crowded Emergency rooms and medical wards. However, of late, these traditional stressors have been aggravated by a health care system that restricts access to operating rooms and procedural suites and by budgetary issues originating in the Ministry of Health and Long-term Care that have flat-lined hospital budgets (making care delivery challenging) and unilaterally reduced physician reimbursement. Clinically, physicians are under increasing pressure both external and internal to “perform” and deliver service as measured by many metrics (and I must accept responsibility for some of this stress). They need to see a certain volume of patients, teach, attend rounds, etc. This is a formula for productivity and provides great public accountability; however, this metric-based system is not conducive to physician happiness. When accountability rules are put in place physicians can feel a loss of autonomy (even though the accountability metrics were established by colleagues and the monitoring and appeal of these rules is determined by a committee of 10 peers). However, accountability is in the air and physicians are not exempt from some level of scrutiny.
Less in the public eye are stressors related to the non-clinical domains in a physician’s life, such as performing research or delivering education to medical students and residents. Non-scientists may not appreciate the highly competitive nature of research. Research groups are like essentially small businesses. They are run by a Clinician-Scientist. They have employees (scientists and technicians) who are paid by grants. The researcher makes ideas and sells them through publications and patents. Obtaining funding is required to meet payroll and to justify dedicated research time. Staying afloat as a Clinician-Scientist is challenging in an era of contracting CIHR funding, in which only~ 15% of grants are funded (a 10% lower rate than a decade ago).
Likewise, physician educators are stressed as they deal with hyper-evolution to Competence by Design (CBD) a new way of educating students and residents’ education endeavours). CBD is a multi-year initiative to implement a competency-based medical education approach to residency education and specialty practice in Canada. It will align local educational practices with evolving Royal College policies and processes using a new CBME approach. It’s exciting and has promise (and Queen’s is at the forefront). However, CBD will be a lot of additional work and the electronic and ancillary staff required to support program development and implementation have yet to be delivered.
In an article entitled, Physician Health: Putting yourself first, the Canadian Medical Protective Association (CMPA) has devoted significant attention to physician wellness. They note that physicians are at risk of burnout or stress because of intrinsic personality traits that may cause us to ignore our health and our life outside of Medicine. We are often perfectionists, over-achievers, and many of us have a tendency to over-work. In addition, we come from a culture of sacrifice-the nobility of long hours of work and a reluctance to acknowledge personal challenges or to ask for help. This makes us vulnerable to depression, stress, anxiety and burnout. My colleague, Dr. Mala Joneja gave me another reason to promote happiness and to identify and counteract burnout. She noted that when burnout occurs, “Everybody loses out - the physician who quits, the colleagues that need the help of the departed physician, and the patients. So, while increasing happiness/satisfaction is desirable, there is also this very real threat if an organization doesn't stay on top of it.”
Dr. Mala Joneja, Interim Chair Rheumatology
Thus, while measuring happiness is important I felt some stress and anxiety in asking my colleagues whether they are content. Asking the question raises the issue of what to do if they are not happy? Could merely asking the question open Pandora’s box? I also worried that the rules I make or administer as the Department Head might be a detractor from our faculty’s GNH. On the other hand, it is my responsibility to try to create a community of physicians who are happy and feel content with their profession and their workplace. Thus, it was with some trepidation I decided to ask my colleagues the happiness question (using a survey that ensured their anonymity was protected).
Here are the questions that were asked and the responses we received:
What can we conclude from this snapshot? It appears that the GNH of members of the Department of Medicine and citizens of Bhutan are not dissimilar. Approximately 70-80% of faculty are happy (or at least satisfied); 10-20% are not happy. What is uncertain is how best to ensure these results are maintained or improved.
Looking forward: To this end, Dr. Stephen Vanner, Deputy Head of Medicine, will be leading a retreat in the spring of 2015 on the subject of physician wellness (Date to be determined). The retreat will feature local experts, such as Dr. Leslie Flynn (Vice-Dean, Education, Faculty of Health Sciences), Dr. Mala Joneja (Associate Program Director, Core Internal Medicine Program), Dr. Renee Fitzpatrick (Director, Student Affairs), Mr. Chris Gillies (Medical Affairs Director, KGH & HDH) as well as speakers from the University of Ottawa’s Physician Wellness program (Dr. Caroline Gerin-Lajoie, Director, Faculty Wellness Program).
I hope you will provide feedback on how to optimally measure and improve GNH and suggest means of improving physician wellness. I particularly welcome the feedback from those who are unhappy with the Department’s rules, regulations and metrics. Your voice is welcome and it should be aired in the same constructive manner in which the rules of our practice plan and accountability framework were created (in our monthly Divisional and Departmental meetings)
Advice: In closing I offer a 2500-year-old piece of advice on how to achieve happiness from Lao Tzu, the founder of Taoism (the Pharrell Williams of the 6th Century BCE)
"If you look to others for fulfillment, you will never be fulfilled. If your happiness depends on money, you will never be happy with yourself. Be content with what you have; rejoice in the way things are. When you realize there is nothing lacking, the world belongs to you." Lao Tzu