When I was preparing for a panel on burnout and wellness for the Triological Society Combined Sections meeting held in January 2018, I came across a large national survey on job satisfaction in the workplace by Tom W. Smith, director of the General Social Survey at the National Opinion Research Center at the University of Chicago (“Job Satisfaction in the United States.” Published April 17, 2007.). In this study, Smith reports the most satisfying jobs in the United States. While most might agree that the changes in healthcare over the decades have not led to improved physician satisfaction at work, I was still shocked to find that we aren’t even among the top 10. Here’s who topped the list:
- Physical therapists;
- Education administrators;
- Painter, sculptors, related;
- Special education teachers; and
- Operating engineers.
Smith pointed out a common theme among these different jobs: “The most satisfying jobs are mostly professions, especially those involving caring for, teaching, and protecting others and creative pursuits.”
But wait a minute … we are a profession too and, arguably, the prototypical profession. We espouse all the elements that he cites, and I argue that we remain one of the most highly respected and important professions in our community. So, why aren’t we listed here among the top most satisfying jobs? Many reasons may come to mind. At the end of the day, however, we do and should have very high expectations of having satisfying work despite the various stressors that are intrinsic to our occupation.
So where does our expectation come from for satisfaction and reward in work? What makes us think that our work should be joyful and satisfying? Is this somehow intrinsic to work?
With just a little bit of thought, one can see that joy and the expectation of satisfaction in work is not intrinsic to work at all. When you look at the dictionary definition of “work,” there is nothing at all about intrinsic joy or satisfaction. Work for many, perhaps most, is simply what one does to earn a living that then enables them and their family to enjoy other aspects of life. So how is it that we physicians (though not certainly physicians alone) expect our work to be joyful and satisfying?
Tying this into Smith’s perspective, this is primarily because physicians have created a profession dedicated to health and healing and have, over time, built a highly developed guild-like solidarity and established systems of rigorous training and practice in that service. And as it turns out, it’s primarily the occupations that people generally understand to be professions—such as medicine, law, and teaching—in which the expectation of satisfaction is built into the work. Also, in most Western societies, a tradition has evolved in which the laws of the nation enabled professions to emerge and become relatively autonomous and self-regulating entities, so long as they maintain an implicit social contract to hold themselves and one another to the highest standards and continue to put service—understood popularly as “professionalism”—above collective or personal gain.
How much is the huge upsurge in burnout and other forms of distress and dissatisfaction that we have been experiencing over the last two or three decades been the result of the chipping away of our professional roles and responsibilities?
As Canadian physician William Osler, MD, put it, “Medical Professionalism is characterized by four great features: Its noble ancestry, which includes the critical sense and skeptical attitude of the Hippocratic School that laid the foundation for a modern medicine; medicine’s remarkable solidarity; its progressive, scientifically-based and forward looking character; and its singular beneficence and basis in charity.”
Putting this into more modern language, as a profession, we not only put others’ well being ahead of our own, but we develop and maintain rigorous schools and science-based curricula. We set recurring accreditation standards for every aspect of our training. Even as accomplished professionals, we are regularly recertified. Expectations for achievement are high. We have built a profession around a calling with high ethics and high standards that is considered prestigious and is held in high esteem by our fellow citizens—even if at times we don’t feel that way.
We are a profession that has defined and pledged itself to a special societal role: to create and cultivate the appropriate conditions under which health and healing can best be promoted and accomplished.
So, if the most satisfying jobs largely are professions, does the fact that we don’t make the list of most satisfying jobs have anything to do with the health of our profession?
In 2011, Robert Tenery, MD, who writes a sometimes-tendentious blog on the challenges of organized medicine, said this in his entry entitled “What If There Were No AMA?”:
“Somewhere between the empty front porch swing and the illuminated CRT screens atop desks in semi-darkened rooms across this country, society’s priorities have shifted from community to self … Accustomed to those conveniences, but not wanting to individually participate, collectively, we are letting the responsibilities and social inequities that need almost constant adjustment, fall to others” (Published January 10, 2011.).
This, in my mind, speaks to some very important truths. With the vast expansion of medical knowledge, it is known to all of us and makes sense that medicine has become increasingly subspecialized. It follows that specialty and subspecialty organizations have grown. We need our specialty societies to be strong to represent the aspect of our work that is unique to each discipline. However, it surprises me how few physicians participate in organizations that represent the entirety of the profession. Less than 25%of practicing physicians are members of the American Medical Association (AMA), down from 75% in 1950. We need our large organizations like the AMA and the American College of Surgeons to focus on the broader issues that we have in common as healers and to represent the whole of our profession. They can represent us in what the healthcare system changes are doing to the role of physicians, the over-regulations that create nonhealing work for us, the growth of managers who are micromanaging our lives and are primarily concerned about output and not about patients first. So, how much has the fragmentation of medicine over time diminished our influence and our capacity to self-regulate as a whole? How much has abandoning our local and national professional societies that represent us collectively left us to fend for ourselves?
If we are abandoning the organizations that represent us collectively, be it at the local, regional, or national levels, is it because we feel they are not representing our interests or are too costly? If so, I would argue that there is an imperative to become more involved and to work to change the organizations that embody us collectively. At a minimum, supporting these organizations financially seems like a healthy investment in our profession to me.
As a follow-up question, how much has adherence to traditional, silo-based practices and resistance to collaborative teamwork contributed to the ceding of control of our work and work environments to other interests and goals, be they corporate, institutional, or bureaucratic? How much has a focus on institutional revenues and maximizing personal income affected medicine’s standing as characterized by “singular beneficence and basis in charity?”
This brings us to another, seemingly simple, question: How much of our professional standing have we been ceding because, in some measure, the public may not see our collective investment in the pursuit of health and healing as the top priority? How much is the huge upsurge in burnout and other forms of distress and dissatisfaction that we have been experiencing over the last two or three decades been the result of the chipping away of our professional roles and responsibilities? Perhaps if the public saw our collective commitment to them more clearly, then we would have a powerful ally to protect us in the long run.
These questions all point to one critical factor: the health of our profession as a profession. This deserves at least as much attention as all of the other remedies that we pursue in our quest for satisfaction in our work environment, from personal coaching to process changes to organizational reforms. Bound together, we have the power to preserve our profession. Divided, we will succumb to the commodification of medicine.
Dr. Johns is director of the USC Voice Center and division director of laryngology at the University of Southern California in Los Angeles. He is also a deputy editor of ENTtoday.