Central PA Medicine Fall 2017 - 15

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As a result, I believe that someone's life was
saved. I hope that a future doctor became
smarter. I'm confident that the work on
case reports opened the door to a part-time
research career that led to some meaningful
peer-reviewed publications.
But I am convinced that those years laid the
foundation for an intensely rewarding career.
Unlike many of my colleagues, when I look
back, I would do it all over again.
"TITHING"
Whatever we may think about the merits of
The Bible, I don't think it's an accident its ancient
authors discerned the value of weekly "down
time" (otherwise known as "The Sabbath") and
allocating a portion of income to a higher good
(otherwise known as "tithing"). Given how
hard life must have been thousands of years ago
in the Middle East, it's telling that they knew
the value of a "time-out" to honor what they
regarded the source of their livelihood. And,
as testimony to its importance, tithing was not
just any tenth of their harvest, but the first tenth.
Fast forward a few thousand years to a different
continent with a different culture involving a
freshly minted doctor. Many weekends were free,
so half a day out of a baseline 5 day workweek
was functionally a tithe.
While my employer, my patients and I gave
up some time, access and money, I believe we
gained a lot more.
BACK TO THE FUTURE
In the meantime, there's an emerging
perspective among physicians that the "Triple
Aim" of health care - patient experience, quality
and costs - needs to be supplemented with
a "fourth aim" of "improving the work life
of physicians and staff" (1,2). This has been
prompted by reports of physician burnout,
professional dissatisfaction and dangerous
levels of anxiety and depression (3,4). To
address this, observers have recommended
regularly assessing physician wellbeing with
validated surveys, fostering a greater reliance
on team-based care, modifying or eliminating
the "busywork" of the electronic health record
(EHR), reducing patient-flow volumes, increasing local physician management control and

using "work-home" balance as an additional
business criterion (1,3,4).

to greater diagnostic accuracy and a reduced
risk of allegations of malpractice. Unhurried
contemplation with deliberate decision-making
can increase a sense of control. Taking a small,
but significant amount of time for "self" can
increase a sense of self-worth. Discovery can
increase a sense of professional mastery. And
while patient throughput may suffer, that cost
is far less than the toll of physician turnover
and primary care shortages.

While these interventions are based on
sound public healthcare policy, they are also
burdened by significant challenges. Monitoring
of physician mental health is intrusive and time
consuming. Team based care will free up time,
but there are considerable "upstream" economic
incentives underlying workflows that will use
that time for more physician-based care. The
promise of a physician-friendly and efficient
It's also far simpler than anything proposed
EHR has yet to be fulfilled, and is unlikely to date.
to happen anytime soon. The non-physician
administrators presiding over most clinical
Physicians, this is your time. Take it. After
settings are unlikely to reduce patient throughput all, you live by more than bread alone.
or yield administrative control. Finally, "workhome balance" may sound good, but may be
destined to become just more adminospeak, like
REFERENCES
"patient centeredness," or "medical neighborhood."
While administrators, policymakers and
academicians grapple with the fourth aim, I
suggest that physicians may want to ponder
the merits of "tithing" to the greater good of
their profession by taking time away from the
press of medical care to reflect, study, educate
and research. Half a day a week is a good target.
While this may not be for everyone, and the
barriers to doing this are significant, the potential
professional and personal benefits may outweigh
the loss of income. Giving physicians "space"
to muse about a differential diagnosis can lead

1. Bodenheimer T, Sinsky C: From Triple to
Quadruple Aim: Care of the patient requires
care of the provider. Ann Am Med November/
December 2014;12(6):573-576
2. Sikka R, Morath JM, Leape L: The Quadruple
Aim: care, health, cost and meaning in work.
BMJ Quality and Safety. 2015;0:1-3
3. West C: Physician well-being: Expanding the
Triple Aim. JGIM 2016;31(5):458-459
4. Linzer M: Building a sustainable primary
care workforce: Where do we go from
here? J Am Board Fam Med March-April
2017;30(2):127-129

Central PA Medicine Fall 2017 15

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