Loneliness Plagues Physicians, but Fixes Are Available:
In an era where technology is allegedly making work "easier" and efficiency is a top priority, loneliness is creeping into the lives of physicians, jeopardizing their mental and physical health as well as the quality of care they give their patients, according to two recent perspective pieces in the New England Journal of Medicine.
The feelings of isolation start soon after residency, writes Ameya Kulkarni, MD, of the Mid-Atlantic Permanente Medical Group in McLean, Virginia, in his January 24 commentary. As residents, doctors could seek comfort, solidarity, and "rehabilitation" in the lounge, where "achievement of personal milestones was amplified by collective experience, and shared pain seemed to wound less."
Sharing pain was a survival tactic, he writes, but the lack of such a safety net in post-residency practice is jarring even when one expects it.
"There's just something unique about being the 'one,' as the attending, to make those decisions and live with the consequences," Kulkarni told Medscape Medical News. "We're on that line of life and death, and facing that by yourself can be very lonely. It caught me surprise in the sense that I didn't expect the emotion even though I knew it was coming."
But it's more than physical loneliness. Even surrounded by people, real and virtual, the expectations and demands of being a physician today deprive doctors of necessary, meaningful time for reflection, argues Richard P. Wenzel, MD, emeritus chairman and professor of the Virginia Commonwealth University Medical Center Department of Internal Medicine, Richmond, in a separate commentary.
Doctors have so much to juggle — from family and financial responsibilities to administrative documentation and compliance requirements to actual patient care — that they have little opportunity for "inhabiting that uplifting, quiet place where we know who we are, where we are going, and what we hold to be true," Wenzel writes.
While this problem certainly afflicts more than just doctors, the stakes are higher in medicine — "health vs disease, suffering vs comfort, life vs death"— Wenzel told Medscape Medical News.
"The key to a best outcome involves time — to speak with a patient to understand the history, to perform a careful examination, to formulate and articulate a diagnosis, a plan, and measures of success," he said. "The erosion of such time is detrimental to the health of the patient and the physician."
Wenzel places the blame partly on "the institutional goals of abbreviating hospital stays and accelerating clinic visits" but also on a more insidious and complicated target that Kulkarni mentions as well: technology.
Technology: Good, Bad, and Ugly
Although technology has improved some aspects of care, it has reduced personal interactions with patients and colleagues.
"The advent of online patient portals has generated increasing quantities of email communications, often in lieu of face-to-face discussions," Wenzel writes. "Thanks to expanding digitization, we no longer need to engage our colleagues in the laboratory or radiology suite while on rounds or to discuss recommendations with a consultant."
Doctors watch the computer as they type in the clinic instead of making eye contact with patients, which indeed saves time — but at the cost of empathy and satisfaction for both the doctor and patient.
"Between patient visits, we may be tempted to squeeze in an email, send a text, or post on social media, hoping to connect with friends and colleagues," Wenzel writes. "But these acts of outreach too fall short of relating."
Social media as a replacement for in-person interactions will leave people more lonely, Wenzel and Kulkarni both said.
But using technology to "augment our regular day-to-day interactions" can be a powerful opportunity to connect with others, Kulkarni said. He describes in his commentary how social media, particularly Twitter, has been a balm for him, especially at certain times of the year, such as the holidays.
And technology itself is not the enemy, but a tool to be wielded.
"The provision of high-quality care requires empathy and connections with patients, but also novel and creative approaches and the wise use of new technology," Wenzel writes.
The trick is to design technological processes within the right framework.
"All new policies and all new technology should have as its primary focus the patient and then the physician," he told Medscape Medical News. "Advances are made not by the answers but by the critical questions asked: How will this help the patient? How will this help the physician?"
For example, information technology teams could study "the benefits and shortcomings of centralizing clinical billing with the goal of implementing such a system" to free up doctors' time, Wenzel writes.
Impact of Loneliness Is Not Trivial
Research has established that loneliness can have serious adverse effects on physical and mental health, including increased risk of illness, according to Amy Banks, MD, director of advanced training at the Jean Baker Miller Training Institute at the Wellesley Centers for Women in Massachusetts.
"The human body works most efficiently and effectively when in a healthy, supportive community," Banks said in an interview. For example, the "smart vagus nerve" is a neural pathway in the autonomic nervous system that activates "when you are engaged in a healthy relationship," she said. It "feeds into the sympathetic nervous system — the flight or fight response — telling it to stand down so you end up feeling calmer when you have a support system you trust." Otherwise, stress levels rise and risk turning into chronic stress, which can weaken the immune system and increase the likelihood of illness.
"I think the only way to help doctors to make room for connection in their busy lives is to provide them with the very real evidence that being lonely and disconnected has dramatic health implications — much higher rates of all illnesses and earlier deaths," Banks told Medscape Medical News. "I think if they had the information about the relatively new neuroscience of human relationships, they would be motivated to both support healthy connections in their patients and within themselves."
Wenzel and Kulkarni already have an intuitive sense of this danger — and what it can lead to.
"When we're lonely, the normal support structures we use to cope with our job go away, and we start to seek them out less, and it contributes to burnout," Kulkarni said. "All the things that have been associated with burnout can be partially attributed to loneliness." Effects of burnout include depression, turnover, early retirement, family and relationship problems, and increased risk of suicide, substance misuse, and medical errors.
At least some of the problem, Banks said, may stem from Western cultural influences, particularly in the United States where people have "the distorted notion that the goal of socialization is to build strong, separate individuals capable of 'standing on their own two feet.' "
While this problem permeates all American institutions, it especially thrives in professions with more power, such as medicine, she said. "This gives people a very skewed message that if they 'need' others, they are weak or less than," Banks said.
Real change will therefore require systemic recognition of the impact of loneliness.The culture of medicine has to change from the top — doctors need to know that the most important factor in health and well-being, for their patients and themselves, is having mutual, healthy relationships," Banks said. "That needs to be reflected in building communities and organizations where that connection is as important to the financial bottom line as seeing dozens of patients."
Despite the Pressures, Solutions Exist
Change needs to start in the institutions themselves, because loneliness is not an intractable problem.
"Addressing physicians' loneliness in the 21st century requires finding innovative ways to interact with each other," Kulkarni writes. His own institution has made it a priority to battle loneliness and implemented a variety of strategies: regular get-togethers outside of work; a weekly group email in which one physician shares an autobiographical essay that doesn't mention work; a midnight snack program with a rotating schedule of volunteers who bring food for those on overnight shifts; a project bringing together small groups of physicians focused on solving operational barriers in practice; and "Finding Meaning in Medicine" sessions, during which doctors discuss their experience of clinical care with emphasis on "concepts like compassion, awe, and loss."
The get-togethers range from simple "happy hours" to specific activities tailored to a wide range of interests, from golf and musical jam sessions to art and cooking classes. Though the challenge looms large and each of these are small steps, together they "gradually build a framework for connecting every physician in our practice to at least one colleague," Kulkarni writes.
Innovation isn't the only option though. Wenzel describes how he encouraged connection, camaraderie, and conversation with the strategy that has brought humans together for millennia: food.
During a sabbatical at the London School of Hygiene & Tropical Medicine, Wenzel came to recognize the value of teatime, when "the entire faculty and graduate student body assembled every day at various tables in one room, where conversations flowed, ideas were exchanged, mentoring flourished, and perhaps most important, trust grew."
Back in the US, he lobbied for a 24/7 dining room and retreat center with free tea and coffee and computer banks for work. The result was cross-department familiarity and conversation, which might help "boost institutional creativity, invigorate professional life," reduce "polarization of clinicians and administrators," and facilitate the frank conversations necessary to confront difficult choices, Wenzel writes.
Such a common room must be in a convenient location and close to patient care so meetings there can be integrated into the workday, Wenzel told Medscape Medical News, and the key is to foster face-to-face conversation.
"The parties can see the body language. They develop trust and closeness and meaning," he said.
These approaches are effective because the most important tools for combating loneliness is "building a community and support system of trusted friends and colleagues," Banks said. "The biggest thing an institution would need to do to build trust in physicians is to build the structures that allow healthy interaction between colleagues and to value outside connections and interests that physicians have."
But even if institutional support for strategies like these isn't forthcoming, physicians can still take steps to address the problem, as a group and individually.
"The things we've done are really low-cost or budget-neutral, and it just takes some initiative," Kulkarni said, and getting the ball rolling often has a snowball effect when an institution sees what's happening. Physicians can also reach out to the administration to discuss operational needs and improvements to start the conversation.
"Shared Pain Wounds Less"
Individually, physicians need to be willing to seek help — a difficult step for doctors, Kulkarni admits.
"You need to recognize where you are and do a self-check on your support structure and who is helping you get through these tough times," he said. "If you find you're in the wrong place, then ask for help."
The bottom line is that solving a problem that partly results from too little time for reflection or interaction with others will require reflection and working with other people, Wenzel suggests.
"We need uninterrupted time to reflect, to converse, and to grapple with the downsides of the unrestrained embrace of technology," he writes. Technology use and "RVU medicine" have "conspired" to create professional loneliness and a crisis in job satisfaction, he writes.
"It seems high time to challenge the assumption that increasing the rate of patient encounters and thereby increasing income is always beneficial for hospitals, practices, and individual practitioners," he writes. "Studies have shown that professionals are less likely to be motivated by extrinsic factors such as money and more likely to be inspired by autonomy, mastery of skills, and a sense of purpose."
Then there is the simple fact that physicians carry a heavy burden when standing on that line between life and death, Kulkarni notes.
"We owe it to our colleagues, and our profession, to insist that no one bear these burdens alone," Kulkarni writes. "The act of healing is more joyful when it's communal, and shared pain wounds less."
And even if physicians know that intuitively, it needs to be openly acknowledged too, Kulkarni told Medscape Medical News.
"I feel like this is something we don't talk about enough that we should talk about more," he said.
None of the interviewees or authors have disclosed relevant financial relationships.
N. Engl. J. Med. Published January 24, 2019. Full text (Dr Kulkarni), Full text (Dr Wenzel)