It is a truism now to say that that pandemic has upended our healthcare system.

It stretched in terms of the ICU bed capacity; it stretched it financially and organizationally. But most importantly, it put to the ultimate test the human factor. The most vulnerable, and at the same time the most resilient, element of the system.

And exactly this aspect of the healthcare system has already been seriously challenged before. Physician burnout „had been simmering for years” write Drs. Hartzband and Groopman in the June 25th issue of the NEJM (audio link here). The changes in the health care system that lead to it, according to the authors, include “the widespread implementation of the electronic health record and performance metrics.”

These led to a “profound lack of alignment between caregivers’ values and the reconfigured health care system.”

The misalignment is especially malicious because it aims at the core of what motivates clinicians. Medicine is a profession, but it is also a calling. Clinicians are primarily motivated not by the extrinsic motivators, but the intrinsic ones ¹.

What is especially sobering is to see that all three pillars that support intrinsic motivation (below) – the primary driver of physicians’ behaviour – have been reconfigured and altered by the healthcare system changes of the last few decades:

1. Autonomy – is now characterized by the lack of control over our time and even language.
   
2. Competence – is now defined as compliance with various metrics.
   
3. Relatedness – is now primarily lip service given to “patient-centeredness.”
   

Is it surprising that the burnout has been so prevalent?

Now, during the pandemic, we have all seen countless examples of altruism, devotion and collaboration. The authors argue that, ironically, the current crisis has “catalyzed the restoration of some elements of autonomy, competency, and relatedness.”

That it perhaps has given us a chance to see that the system 1. Can be changed and 2. That these changes may lead to the restoration, at least partial, of our autonomy, and enhanced sense of competence and relatedness.

One issue that the pandemic has catalyzed was the widespread adoption of telemedicine. It has offered some increased flexibility, allowed clinicians better control over their schedules, and provided a way to stay in touch with patients. And most of them appreciated it.

However, I am worried that rapid introduction of telemedicine, even though beneficial in many aspects, has the potential of altering the patient-physician relationship and we need to think carefully about what how to best implement it. Many studies (here, here, and here) are now being done to examine this issue.

One thing is clear: “We must not return to the former status quo.”

1. This idea is borrowed from the work of Gagne and Deci, organizational psychologists who studied the motivation in the workplace. ↩
2. Citation: Hartzband P, Groopman J. Physician Burnout, Interrupted. N Engl J Med. 2020;382(26):2485-2487. doi:10.1056/NEJMp2003149