Culture of Self-Sacrifice

Authored by: Alex McDonald, MD, FAAFP, CAQSM

Self-sacrifice can mean many things and take on many forms. Within medicine, the ubiquitous culture of self-sacrifice allows us—and is often required of us—to persist and achieve the academic and time requirements necessary to become a physician. But this culture is also our downfall. Nobody goes into medicine just for the glory or economic stability. There are far easier and faster ways to achieve that. The long, hard path to becoming a physician requires dedication to medicine, to the service of others, and is, in many ways, self-sacrifice. Many of us spent most of our 20s and some of our 30s in school and training as many friends had already launched successful careers or started families. However, that last aspect of self-sacrifice has at times been taken too far, and is, in part, contributing to physician burnout, and lack of professional satisfaction. I clearly remember as a medical student overhearing residents bragging about a 36-hour call shift or working 30 days consecutively without a day off.  Naturally, this led to the implementation of ACGME residency duty hour restrictions, which I fully support.

For a new physician, this outward demonstration of their commitment to medicine and patient care can be exciting and somewhat rewarding, given they are able to help those most in need and truly fulfill their professional goal of being there for families and patients at a critical time.  However, the unwritten rule or expectation of constantly putting others first can take a tole.  As this culture persists into early mid, and even late career, with increasing demands from regulators, employers, patients, and now even politicians, those pressures continue to accumulate and take a toll; they are also hurting patients, physicians and the health of our nation. In some settings, if a physician advocates for themselves or says they need a break, time off, or even just reduced clinical demands, it may be perceived as weakness, when in fact it may be precisely the right thing to do to preserve quality of care, patient safety, and/or the physician’s own mental health. The physician is often seen as the leader of the healthcare team, willing to sacrifice themselves for the team and/or their patients. While this Norman Rockwell version of a physician is slowly changing, which I am happy to report, we still have work to do. In many circles and institutions, the expectation of self-sacrifice persists. Is this really the best thing for patients? Or for physicians?

The airline industry had a similar culture, and some high-profile airline accidents catalyzed a significant culture shift that has made air travel much safer.  Prior to the 1970s, the airline pilot was seen as a hero or nearly invincible, perhaps even a superhuman given the hours and skill required, a person dedicated to their profession. This culture shifted from one of the infallible pilot to one where the team, its safety, and a shared goal became more important than any single individual pilot, skill, or experience. As a result, limits on expectations for a pilot, and the culture of what it means to be an airline pilot, have significantly changed. If an airline pilot has worked too many hours and is too tired, they simply state this, and it’s seen as noble and appropriate to know their own limits and abilities.

Imagine the headlines or the response if a doctor told you that he couldn’t see any more patients or didn’t feel comfortable performing surgery after a long night on call. The ability to acknowledge one’s weakness or limitations as a physician is exceedingly rare in medicine. If there are more patients to be seen or more surgeries to perform, the expectation from health systems, patients, and everyone involved is that the physician on call will simply get the work done.

There are obviously limited periods of time where clinical demands and patient acuity surges and demands placed on physicians and the healthcare system will be greater, and we all must rise to the occasion, like what we saw during the COVID-19 pandemic. However, when high demand becomes persistent and unsustainable, that is where the system breaks down and results in physician and other healthcare worker burnout. When unstainable physician demands and expectations arise, be it self-imposed or system-imposed, overt or implicit, we are all are far less likely to be at our best when providing patient care and interacting with colleagues or other healthcare team members, and we all suffer as a result.

There are many factors influencing the push for physicians to do more and measure productivity. However, the work of a physician cannot be broken down into widgets; this is highly skilled work that ebbs and flows and is in no way constant.  The culture of team-based care, collaboration, and physician workload must be continually re-examined and expectations re-set if we are truly dedicated to maintaining the physical and mental health of our physician workforce.  “Physician, Heal Thyself” is far more complicated than simply a phrase, but we must start looking at ourselves, the culture to which we contribute, and our own expectations before we can fix the system.

No amount of yoga or wellness modules are going to improve the culture of medicine until physicians begin to change our own language and our own self-imposed expectations, how we view our value and work, and our ability to care for ourselves. Being a doctor will never be easy—it’s hard work, it’s gritty work—but it should be fulfilling and sustainable. Only then will we truly be able to improve the health of our nation and fix our broken healthcare system.