AMA House of Delegates
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Efforts at Saint Louis University School of Medicine, which Leon Vorobeichik, MD, just graduated from, lowered student rates of depression and anxiety. Dr. Vorobeichik is the student member of the AMA Council on Ethical and Judicial Affairs. Photo by Peter Wynn Thompson / www.peterthompsonphoto.com

AMA meeting: Low morale a problem at every physician career stage

Delegates applaud the Association’s strategic focus on physician satisfaction. A CEJA forum examines burnout among doctors and medical students.

By Kevin B. O’Reilly — Posted July 1, 2013

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The Council on Ethical and Judicial Affairs is exploring the ethical dimensions related to the American Medical Association’s strategic initiative aimed at improving physicians’ professional satisfaction.

As a first step in that process, the council’s open forum at the AMA Annual Meeting featured three presentations about factors driving the alarming rates of burnout and dissatisfaction among medical students, residents and physicians.

For medical students, the vast amount of material they are expected to master combined with starting life at the bottom of the medical totem pole can prove deeply unsettling, said Leon Vorobeichik, MD, the council’s student member.

He recently graduated from Saint Louis University School of Medicine, where student surveys told a sad tale. When surveyed during orientation, only 6% of students in the school’s class of 2011 reported depression, while a third were anxious. By the end of the first year of medical school, the depression rate rose to 27%, while nearly 60% of students had moderate to high anxiety symptoms.

However, a comprehensive initiative at the school has helped address the problem. The program combined wellness-promotion activities such as mindfulness training with year-long elective courses and integrated opportunities to do volunteer activities outside the classroom.

Courses also were scrutinized to see if they could be shortened or the workloads lightened without sacrificing educational value. For example, a 10-week anatomy course was cut to eight weeks.

The changes are having an impact, with the Class of 2015 reporting a depression rate of 11% and anxiety rate of 31% after year one of medical school.

“There is hope,” Dr. Vorobeichik said.

Meanwhile, efforts to reduce burnout among medical residents appear to be having limited effect, according to Katherine L. Harvey, MD, MPH, CEJA’s resident/fellow member and a medical oncology and hematology fellow at Yale Cancer Center in New Haven, Conn.

The 80-hour-a-week duty restrictions mandated by the Accreditation Council for Graduate Medical Education have led to an increase in risky hand-offs and frustration among many residents who feel they are being cheated of valuable opportunities to learn.

“Residents generally did not use the extra time for sleeping, and it’s hard to say [the duty-hour rules] improved quality of care. They faced more pressure to do more work in less time,” Dr. Harvey said.

She added that residents also face an ethical dilemma when reporting their duty hours. Accurately reporting excess time on duty could result in penalties levied against the programs residents are counting on to further their own careers.

In open forum testimony, delegates agreed that the focus on professional satisfaction should occur throughout the continuum of a physician’s career.

“We go into medicine for all the right reasons, and if we’re lucky, we don’t have them beaten out of us by the training,” said Craig A. Backs, MD, a Springfield, Ill., internist and alternate delegate for the Illinois State Medical Society.

Yet the troubles do not end with entry into medical practice. Research shows that about one in three practicing physicians is burned out and that doctors who are professionally dissatisfied are likelier to have less-satisfied patients.

High burnout rates are not just a problem for physicians, but for the country as a whole, said Michael Tutty, PhD, the AMA vice president of physician practice sustainability.

“Our society is best served when our brightest minds consider, choose and enjoy a fulfilling career in the medical profession and provide high-quality patient care,” he said.

AMA research expected in fall

The AMA has partnered with the Santa Monica, Calif.-based nonprofit think tank RAND Health to do field research at 30 physician practices in six states to better understand the elements linked to dissatisfaction and how to address them. The early themes emerging from the project are that unstable revenue streams, lack of control over the practice environment and less time with patients are the primary culprits of physician dissatisfaction, Tutty said.

The initial findings probably will be released in October, and the AMA will work to develop tools to help physicians address the factors impeding satisfaction while advocating for changes in areas beyond doctors’ direct control.

At a separate educational session, Jay Crosson, MD, said the AMA action plan probably will include toolkits and webinars for physicians, and dissemination of the project findings through media mailings and speaking engagements. Dr. Crosson is the Association’s group vice president, professional satisfaction — care delivery and payment.

“We are going to take all these factors and try to understand the key drivers. From that we will create an action plan,” he said.

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ADDITIONAL INFORMATION

Meeting notes: Medical ethics

Issue: Physicians can identify and help the victims of human trafficking in their patient populations, yet many doctors have not been trained on how to do so.

Proposed action: Encourage AMA member groups, sections and the Federation of Medicine to raise physician awareness about human trafficking and inform doctors about the resources available to help them serve affected patients.[Adopted]

Issue: Forty-four states require transgender patients to have undergone sex reassignment surgeries to change the gender designation listed on their birth certificates. But the standard of care for transgender patients has shifted, with a majority of individuals completing gender transition without surgery.

Proposed action: Support changing jurisdictional policies so that a physician’s verification “that the individual has undergone transition according to applicable medical standards of care” is sufficient to alter the birth certificate sex designation. [Adopted]

Issue: Sometimes there is a conflict between a physician’s refusal to provide a treatment on conscience grounds and patient autonomy and access to care.

Proposed action: Outline the circumstances in which conscience-based treatment refusals are inappropriate, such as when a patient faces a life-threatening emergency and no other qualified physician is available to provide care. [Referred]

Issue: The AMA’s ethics policy says that physicians should not refuse to treat patients on the basis of their race, color, religion, national origin, sexual orientation or gender identity, but does not cover discriminatory behavior by medical students.

Proposed action: Add language to the policy to oppose medical student refusal to participate in patient care for discriminatory reasons. [Adopted]

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External links

AMA on shaping delivery and payment models (link)

“Assessing Individual Physician Performance: Does Measurement Suppress Motivation?” The Journal of the American Medical Association, June 27, 2012 (link)

“Resident Physician Burnout: Is There Hope?” Family Medicine, October 2008 (link)

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