This is very important. Women make up of >50% of medical students, and in pediatrics, the residents have been reported somewhere around 75%. The AAP in 2017 published data showing 63% of AAP members were women. It's even larger today. And women pediatricians do not have the same opportunities for advancement in their careers, don't have pay equity, and often struggle with balancing caring for themselves, their own families, their patients and practices. We MUST look at this problem with the seriousness it deserves. Much of our own "unwellness" comes from systemic pressures that prevent us from having the appropriate resources for caring for our patients. We feel moral injury every day when we go to work and feel like we aren't doing enough to help those in need. To my colleagues who feel that way: I SEE you, hear you and value you. You matter! You matter to many and make a difference every day. Yet it feels like it's never enough and we are losing ground. We need healthcare reform...and lots of it. It's time to stop saying the system is broken...let's heal it, and in the process heal ourselves and allow us to be the healers we were called to be. We will need creative solutions. Let's create them.
Thank you, Dr. Kressly. I was reading Dr. Libby's post and talking to Dr. Nolan Ernest. There are some possible solutions and a lot that I missed.
We need to look at how previous trauma has an impact on our workforce and act in compassionate ways to help heal them.
Loan forgiveness should be universal, independent of how a community pediatrician serves their neighborhood.
Every neighborhood in the USA should have access to a pediatrician that provides a medical home for the children of that community.
The financial policy that creates the payment disparity between the specialty of pediatrics and procedural medicine must be addressed at the federal level to make it possible for mission-driven young doctors can afford to choose community pediatrics.
Pediatricians do best, may be able to immunize against moral injury, and avoid burnout when they are heard and part of a mission-driven community led by physicians. Organizations that are mostly or primarily margin driven are incompatible with the culture of the specialty of pediatrics.
Time to lean into the fact that we need team based primary care and need to blow up the current patriarchal or matriarchal physician only model. Pediatricians in primary care are the last to adopt that the demands of healthcare are changing and have been for decades. Isn’t it ironic how negative pediatricians are toward np’s…. 90% are women…. How about how we treat practice managers, women executives in pediatrics etc… majority women. Even “women in pediatrics” is exclusive to women pediatricians …. And then you can ask how we treat the growing minority of men in the field. Time to sweep in front of our own doors …. My take as someone who loves to live outside the siloes that blind so many in healthcare.
I am curious to your experiences. Do you know any people in the Adult Medicine side of the world that are happy? I promise you that they are all very miserable. More miserable than the Peds people. I am happy at my job, but I am private, and I look forward going to work because I am not afraid of the computer, the patient and Illness in general. This is called experience and if you lack it, well then your life mixed up with a computer and MBA suits running the show will make you miserable.
Thank you, Dr. Connors, for taking the time to read and share your thoughts. I'm puzzled but intrigued by your post. Things like having to work 12 hours overnight shifts after 40, asking a neonatologist to cover the NICU and the Emergency Room, and asking a pediatrician to cover the NICU, the ward, and the ED are what Dr. Dean calls moral injury. It is a moment when you know as a physician that you can't lead your team and care for your patient; you have to choose which one of the critically ill children you will leave without care. One solution is to work with or for a mission-driven company. What do you propose as a solution to the problem?
You know when you rounded on patients, took care of sick kids in the office, took after hours calls, referred less, deferred less to urgent care and ER ….
My moral injury comes from those who decided to let care become fragmented and then complain about the care those of us trying to fill the gaps have to deliver.
Medicine is a demanding profession and it will, by the nature of its altruism and personal demands, have the potential for creating stress and in some cases distress that are conceptualized as burnout. We know that burnout will impact professional and individual wellbeing and can create negative consequences that are reflected in suboptimal outcomes, increased costs, and shorten careers. I have been working through the physicians foundation and the AMA on understanding causes, repercussions, and possible solutions to burnout and supporting professional wellbeing. We have supported a significant initiative through the AAP called WEL, women's Wellness, Equity and Leadership. As noted, the majority of pediatricians are women and there is evidence that they are more susceptible to the demands of professional and family life that resulted in a higher incidence of distress, burnout, and even suicide. These are not easy issues to solve. Understanding the impact of moral injury is something that contributes dramatically yet reflects the current dysfunction of our medical system and the way we can practice to provide the care our patients need. Moral injury results from our inability to provide the complete and necessary care of our patients. It comes from the time constraints and the limitations imposed upon us externally whether it be from our care settings, payers, or societal, it gives us a sense of distress and that can impact this internally. We need to continue to address these issues and monitor how solutions work or adapt to improve how we do address them.
These are very important questions. Currently, I don't sense there is enough emphasis on the looming US Workforce crisis in pediatrics. In my state of Rhode Island it is already a full blown crisis. Unless work and effort is expended by all of us, I'm not sure pediatric primary care will be delivered by pediatricians in the need future. That's not a future I want to live in.
"Put another way, the number of physicians in the U.S. is largely a question about the sort of health care system that we want to have. Fewer physicians per person means that health care services are scarcer. Rather than ensure patients can easily access providers, the U.S. instead systematically directs health resources to high-intensity, often wasteful, treatments. In fact, an analysis conducted by the National Academy of Science’s Institute of Medicine found that unnecessary care was the largest contributor to waste in the U.S. health care system." Excellent article Chip Hart, thanks for sharing.
This is very important. Women make up of >50% of medical students, and in pediatrics, the residents have been reported somewhere around 75%. The AAP in 2017 published data showing 63% of AAP members were women. It's even larger today. And women pediatricians do not have the same opportunities for advancement in their careers, don't have pay equity, and often struggle with balancing caring for themselves, their own families, their patients and practices. We MUST look at this problem with the seriousness it deserves. Much of our own "unwellness" comes from systemic pressures that prevent us from having the appropriate resources for caring for our patients. We feel moral injury every day when we go to work and feel like we aren't doing enough to help those in need. To my colleagues who feel that way: I SEE you, hear you and value you. You matter! You matter to many and make a difference every day. Yet it feels like it's never enough and we are losing ground. We need healthcare reform...and lots of it. It's time to stop saying the system is broken...let's heal it, and in the process heal ourselves and allow us to be the healers we were called to be. We will need creative solutions. Let's create them.
Thank you, Dr. Kressly. I was reading Dr. Libby's post and talking to Dr. Nolan Ernest. There are some possible solutions and a lot that I missed.
We need to look at how previous trauma has an impact on our workforce and act in compassionate ways to help heal them.
Loan forgiveness should be universal, independent of how a community pediatrician serves their neighborhood.
Every neighborhood in the USA should have access to a pediatrician that provides a medical home for the children of that community.
The financial policy that creates the payment disparity between the specialty of pediatrics and procedural medicine must be addressed at the federal level to make it possible for mission-driven young doctors can afford to choose community pediatrics.
Pediatricians do best, may be able to immunize against moral injury, and avoid burnout when they are heard and part of a mission-driven community led by physicians. Organizations that are mostly or primarily margin driven are incompatible with the culture of the specialty of pediatrics.
Time to lean into the fact that we need team based primary care and need to blow up the current patriarchal or matriarchal physician only model. Pediatricians in primary care are the last to adopt that the demands of healthcare are changing and have been for decades. Isn’t it ironic how negative pediatricians are toward np’s…. 90% are women…. How about how we treat practice managers, women executives in pediatrics etc… majority women. Even “women in pediatrics” is exclusive to women pediatricians …. And then you can ask how we treat the growing minority of men in the field. Time to sweep in front of our own doors …. My take as someone who loves to live outside the siloes that blind so many in healthcare.
I am curious to your experiences. Do you know any people in the Adult Medicine side of the world that are happy? I promise you that they are all very miserable. More miserable than the Peds people. I am happy at my job, but I am private, and I look forward going to work because I am not afraid of the computer, the patient and Illness in general. This is called experience and if you lack it, well then your life mixed up with a computer and MBA suits running the show will make you miserable.
George Rogu MD MBA
Thank you, Dr. Connors, for taking the time to read and share your thoughts. I'm puzzled but intrigued by your post. Things like having to work 12 hours overnight shifts after 40, asking a neonatologist to cover the NICU and the Emergency Room, and asking a pediatrician to cover the NICU, the ward, and the ED are what Dr. Dean calls moral injury. It is a moment when you know as a physician that you can't lead your team and care for your patient; you have to choose which one of the critically ill children you will leave without care. One solution is to work with or for a mission-driven company. What do you propose as a solution to the problem?
Go back to when pediatricians were happy.
Tell me what changed?
You know when you rounded on patients, took care of sick kids in the office, took after hours calls, referred less, deferred less to urgent care and ER ….
My moral injury comes from those who decided to let care become fragmented and then complain about the care those of us trying to fill the gaps have to deliver.
It’s all somebody else’s fault .. really?
It is the fragmented care that gave you a job in the ER btw!
Yes. I am part of the problem. Although my job security comes from primary care taking less and less care of their own patients.
Medicine is a demanding profession and it will, by the nature of its altruism and personal demands, have the potential for creating stress and in some cases distress that are conceptualized as burnout. We know that burnout will impact professional and individual wellbeing and can create negative consequences that are reflected in suboptimal outcomes, increased costs, and shorten careers. I have been working through the physicians foundation and the AMA on understanding causes, repercussions, and possible solutions to burnout and supporting professional wellbeing. We have supported a significant initiative through the AAP called WEL, women's Wellness, Equity and Leadership. As noted, the majority of pediatricians are women and there is evidence that they are more susceptible to the demands of professional and family life that resulted in a higher incidence of distress, burnout, and even suicide. These are not easy issues to solve. Understanding the impact of moral injury is something that contributes dramatically yet reflects the current dysfunction of our medical system and the way we can practice to provide the care our patients need. Moral injury results from our inability to provide the complete and necessary care of our patients. It comes from the time constraints and the limitations imposed upon us externally whether it be from our care settings, payers, or societal, it gives us a sense of distress and that can impact this internally. We need to continue to address these issues and monitor how solutions work or adapt to improve how we do address them.
These are very important questions. Currently, I don't sense there is enough emphasis on the looming US Workforce crisis in pediatrics. In my state of Rhode Island it is already a full blown crisis. Unless work and effort is expended by all of us, I'm not sure pediatric primary care will be delivered by pediatricians in the need future. That's not a future I want to live in.
A related document:
https://www.niskanencenter.org/the-planning-of-u-s-physician-shortages/
"Put another way, the number of physicians in the U.S. is largely a question about the sort of health care system that we want to have. Fewer physicians per person means that health care services are scarcer. Rather than ensure patients can easily access providers, the U.S. instead systematically directs health resources to high-intensity, often wasteful, treatments. In fact, an analysis conducted by the National Academy of Science’s Institute of Medicine found that unnecessary care was the largest contributor to waste in the U.S. health care system." Excellent article Chip Hart, thanks for sharing.