The term “Physician Engagement” can be traced back to the concept of “Employee Engagement” as defined by Kahn in his seminal work “Psychological conditions of personal engagement and disengagement at work”. From Kahn’s perspective, people who are engaged deeply in their work both drive personal energies into role behaviors (self-employment) and display the self within the role (self-expression). Without the presence of these conditions the individual’s role and self are disconnected leading to an absence of job satisfaction and achievement.
Later writers have refined Kahn’s concept of employee engagement as “a full state with persistent and positive moods and motivations, with vigor, dedication, and absorption as its major features”.
So how does this apply to physicians?
In the earlier part of this century physicians tended to be sole proprietors who hung a shingle and accepted payment directly from the patient. Today there are still many physicians who run their own practices, but the pressures are mounting, and practices are being rapidly acquired as complex legal, regulatory, technology, and reimbursement practices have taken their toll.
In 2013, less than 35% of physicians ran their own practice or had an ownership stake in a practice. 8% were independent contractors and the remainder either worked for a hospital, another doctor or were employed by a hospital or health system. More tellingly, year over year changes pointed strongly towards doctors becoming employees and not owners of a business.
Today it’s reasonable to posit that at least 60% of physicians are employees of one form or another, and as such many are faced with human resources departments and the concept of “engagement” espoused by Kahn et al. It’s also clear that with mounting demands on their time physicians have a very difficult job to stay engaged.
Consider the following statistics from Dr. Richard Baron who conducted a yearlong review of his own work patterns. In the average day, Dr. Baron and the other physicians in the practice saw 18.1 patients, handled 23.7 phone calls, answered 16.8 emails, dealt with 19.5 lab reports, 11.1 imaging reports, and 13.9 consult reports, issued 12.1 prescription refills, excluding those issued during patient visits and worked 50 to 60 hours per week.
Dr. Baron’s report was from 2010 and while an electronic medical record was in use, he was not attempting to meet later stage meaningful use requirements. With some authors reporting upwards of two hours spent charting in the medical record per shift it seems likely that five years later Dr. Baron and his colleagues may be working even more hours.
Doctors have a noble mission of care that is often conflated with the concept of engagement in the media. After all, who enters medicine except the healthcare priest who is willing to subordinate his life to the good of the community? How can a doctor not be engaged and fully absorbed when their patients come to life under their very hands? Conversely, how much more do they suffer when patients are routinely injured by systems and perceived bureaucracy over which they have had no control?
Generally speaking, most doctors have seen a salary decline in recent years while student loans for medical school have only increased. A recent analysis in MoneyWatch called becoming a doctor a “one million dollar mistake” for young bright students who could earn substantially more in other sectors of the economy. Working harder, taking greater risks, and receiving less return is not a recipe for engagement.
Salary aside, the status of doctors in society has also changed. The indisputable medical doctor of the 1950s is now portrayed as a real, fallible, and sometimes flawed individual. We still respect our providers and rely on their Hippocratic Oath, but kickbacks from Big Pharma, overbilling, and high profile Medicare fraud in the media has taken its toll. Being a doctor isn’t what it once was.
In short, doctors are overworked, underpaid, less respected, and less in control of their destiny than ever before. Combine this with political forces for major healthcare reform and achieving widespread physician engagement becomes an epic task on par with sending a man to the moon!