Clinician self- care
It might be argued that clinicians self-care in ways that put patients’ welfare first. The Editor-in-chief of the British Medical Journal (BMJ), for example, recently cited a contributor to BMJ Careers, who suggested that junior physicians might strike ‘for the good of our patients, colleagues, and the NHS’.1 However, any benefit accruing to patients would be indirect and reflect an underlying need for policy change because the bright light of patient-centred health care casts a vast shadow over clinician welfare. In illuminating first the welfare of patients, this care puts the welfare of clinicians no higher than second. Through physician acts of last resort, such as strike action, clinicians subordinate their welfare as people – and as moral agents – on whom patients depend. Is it really surprising therefore that, in medicine for example, ‘some of the most sensitive and capable physicians today feel like they practice in a medical dark night of the soul’?2 Unlike owls that love the dark more than the light, they tolerate the dark under the misapprehension that patients benefit from occupying the light alone. Left wondering what it means to be a physician and, implicitly, a health professional, these physicians languish in role changes to their professional identity. Whether deprofessionalizing them or redistributing their power and resources to other clinicians such as nurses and pharmacists, the changes weaken physicians’ autonomy to protect human welfare. Fundamental to these changes has been increased external control over clinical care delivery, which can reduce the ability of physicians and other clinicians to work for patients to the best of their ability without neglecting their own self-care. Economic, medico-legal and patient pressures have been adding to these stresses and need for self-care. Consistent with Chapter 3, I mean self-care in the broad sense of however clinicians choose in moral good faith to serve their own welfare as persons professionally responsible for providing health care. Feeling depersonalized, some clinicians have chosen to self-care in ways that detract from patient welfare. For example, they have reduced health care to a commodity, exhibiting inappropriate self-interest that takes advantage of patient vulnerability. Such practice includes over-servicing medical care by increasing
patient volumes and overprescribing or ordering unnecessary tests to raise clinician incomes. The 2002 Physician Charter3 sought to reconnect physicians to core values of service. As a code of moral conduct to protect the welfare of patients and populations, however, it has not helped physicians to self-care. It has kept physicians out of the light by obscuring their moral interests. I am not denying that society takes critical steps to protect clinician welfare, for example by limiting hours of clinical practice out of recognizing the need for clinicians to have time off from work, take vacations, attend conferences and be able to retire. These protections help to expose progress in recognizing the fallacy of the principle of primacy of patient welfare (Chapter 2). Nevertheless, the problem remains that, in medicine for example, aspirational documents such as the Charter reduce physicians to their shadow – a proto-space without physicality – in patient care delivery.4 The Charter misses the point that physicians’ self-care and physician care of patients are not alternatives: these interests are conjunctive and indivisible. If clinicians can care only for others then, as Eric Fromm5 notes, they cannot care at all, since clinicians who do not care for themselves are ill-equipped to care for patients. In these terms, clinician self-care is important for its own sake as well as for patient care. In common with the Charter, health reforms in recent decades have been quiet in acknowledging this reciprocity. Emphasizing the welfare of patients and their communities, they say little if anything about the related need to protect the welfare of clinicians. Believing they already serve patients well, clinicians are put under pressure to change the nature and scope of their work in order to shift costs and meet population health goals without necessarily taking the time they need for self-care and patient care. The reforms therefore have tended to marginalize the status of clinicians – and patients – as people; erode independent clinical control over an expanded body of clinical work; prompt clinicians to maximize their bargaining power relative to others, including hospitals and patients; and produce work stresses that commonly manifest in clinician unwellness. This chapter discusses how pressure on clinicians underpins their unwellness and inadequate self-care in the context of their different values, and approaches to attempting to care for themselves. Clinicians, like patients, should be free to self-care in any ethical manner that is faithful to their deep values, within a project of virtue-cultivation and expression – but their siloed duty of care to patients inappropriately constrains this need.