Privilege and entitlement in “work-life balance”

Did it ever occur to some of today’s physicians that many people work awfully hard and complain a lot less than they do about “burnout” and “work-life balance”?

Did it ever occur to them that “work-life balance” is the very definition of a first-world problem, unique to a very privileged class of highly educated people, most of whom are white?

Every day, I go to work and see the example of the nurses and technicians who work right alongside me in tough thoracic surgery cases. Zanetta, for instance, is the single mother of five children. She leaves her 12-hour shift at 7 p.m. and then faces a 60-mile commute to get home. She never complains, and unfailingly takes the extra moment to get a warm blanket for a patient or cheerfully help out a colleague. When I leave work, I see the gardeners who arrive in battered pickup trucks and mow lawns in the Los Angeles summer heat for slim pay and no benefits. I can’t imagine these people wasting time worrying about work-life balance. They’re too busy working.

Or look at what it’s like to work in one of the world’s top restaurants. Edward Frame, now a graduate student in social research, described his first job in a Michelin-starred kitchen for an article in the New York Times.

“I worked in a small alcove, connected to the dishwasher,” he wrote. “Glass racks came out, I wiped away any watermarks or smudges, and then, just as I finished one rack, another appeared. This went on for hours, like some kind of Sisyphean fable revised for the hospitality industry. By hour two my fingers hurt and my back ached. But I couldn’t stop. The racks kept coming. Slowing down never occurred to me. There wasn’t time. I needed to make it nice. I wanted to make it nice.”

Let’s face it—a lot of people have jobs much worse than being a physician. Apparently, they don’t expect to be coddled or to receive much sympathy about their rate of burnout, or their lack of “work-life balance”. Nor do they expect that workplace expectations will be altered just to suit them.

I can’t imagine having the gall to complain about how tough it is to be a physician when all you have to do is open your eyes and see what’s all around us: people working incredibly hard, making far less money than we do, and then returning home to face the responsibilities of family life, child care, housework, home maintenance, and everything else.

We—physicians—thankfully can afford help with these tasks. The Medscape Physician Compensation Report for 2015 reported that the average compensation for a primary care physician was $195,000 and for a specialist $284,000.

When I was a new faculty member making an instructor’s salary right after residency, it’s true that I didn’t have a lot of take-home pay left after I made monthly payments for student loans, private pre-school for two children, housecleaning help, and a full-time nanny to provide transportation and after-school care. The full-time nanny was essential because a child with a bad cold or an upset stomach needs to stay home, and a physician can’t drop everything to stay home too. These were investments that my husband and I made because we felt that being a physician is important work.

But in medicine, the prevailing wisdom today is that the rigorous culture of the past needs to change—along with the expectation of dedication to duty, long work hours, and stoicism—because it’s all just too difficult and we risk getting burned out.

Now Stanford University has started a new “time-banking” program designed to ease pressure on faculty physicians and basic science professors. As admiringly described by reporter Brigid Schulte in the Washington Post, the program allows faculty members to “bank” hours that they spend on uncompensated activities such as committee work and earn credits to use for support services at home or work.

Dr. Gregory Gilbert, an emergency physician who was the poster child for the Post article, used his credits for delivery of meals to his home, housecleaning services, and employing a “life coach” to help him “find better balance in his life”.

Wait just a minute. I’m sure that Dr. Gilbert is a good person—a divorced father trying to be a conscientious physician and spend time with his children. He must be a smart guy if he’s on the faculty at Stanford. Do you mean to tell me that Dr. Gilbert couldn’t figure out how to order food delivery and arrange for housecleaning before Stanford came up with this program?

Paternalism in action

The sheer paternalism of the Stanford program is breathtaking. The assumption, apparently, is that Stanford faculty can’t be trusted to manage their own lives inside and outside of work. So Stanford needs to nudge them in the right direction, encouraging them to use time-bank credits for support services that free up their time, whether housecleaning or help writing grants.

Why wouldn’t Stanford provide grant-writing help for all faculty members if this is a university goal? Or increase faculty pay by incentivizing areas of the educational enterprise that may be underserved, such as mentoring and committee work? Can’t the faculty be trusted as intelligent adults to spend their own money as they choose?

I wonder, too, what California taxpayers would think if they realized that some of the dollars they pay in support of Medicare and Medi-Cal are paying for physician “wellness” programs rather than for patient care services. The Stanford time-bank program was funded “largely”, but not entirely, by the Sloan Foundation, according to the Post. Though Stanford is a private university, it receives millions in public funds every year as do all academic medical centers. Medicare pays directly for healthcare services, and Medicare funds support graduate medical education programs and faculty salaries.

Reading between the lines, it appears that Ms. Schulte has perhaps overstated the success of the Stanford program. She admits that the emergency department’s time-bank program is “all that’s left” of the more ambitious, two-year pilot program that was originally started, and that other departments in the university haven’t embraced the concept though it still has enthusiastic supporters.

Meanwhile, I don’t see why Dr. Gilbert, as an affluent single father, inherently deserves more help with “work-life balance” than does Zanetta, the surgical technician. He’s an American university and medical school graduate, and a clinical associate professor at Stanford. Zanetta’s goal someday is to go to college and become a registered nurse. I’m sure she would love to come home to a clean kitchen and find a fresh meal delivered to her door. But “burnout” and “work-life balance” are the vocabulary of privilege and entitlement. Everyone should be lucky enough to have these first-world problems.

Cartoon image from Doonesbury, by Garry Trudeau

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Karen, Excellent article. I laugh whenever I hear of “work life balance”, and I think back to our days (I came a bit later) roaming the ORs of the south pavilion of Yale-new haven as an anesthesiology resident. How is it that the medical specialty which works the LEAST hours per week on average, ER, needs more work life balance!? The shortage in their specialty results in their earning a kings ransom for part time hours. What would the public think if they knew that these folks are earning 300-350/hr!? Love your stuff! Fellow Yalie

EM physicians work the least amount of hours on average because they’re working the most weekends, holidays and overnights of all specialities. What would you think if the daytime hourly salary for a Stanford EM physician is $70/hour pre-tax, not $300/hour. The overnight hourly wage that Dr. Gilbert makes is not even half of your $300/hour figure. Please be aware of your facts before you degrade another specialty.

why do you have such a chip on your shoulder about people wanting work life balance? Just looking at the side bar you have another article about Virginia Apgar and whether she would have worried about work life balance. And of course your widely read article about women working part time. Wondering what emotions are really underlying this. Me personally, I work locums permanently and my 20 hours a week makes me more money than I was offered full time working at my residency program after completing training. I only need a nanny 4 hours a day and I don’t answer my phone when I am off the clock. I am very happy and love my work life balance. I put myself through med school and dont owe anyone anything. You must hate me!

Dear Dr. Bellanti– I think my essential problem with the concept is this: the opposite of work is not life. The exact antonyms are leisure, rest, idleness, etc. The opposite of life is death. I would be very sad if my work was so distasteful that in my mind I was only able to “live” or enjoy life when I was away from work. I truly do believe that medicine should be a “life’s work”, not something that you do only when you’re forced to, and that you can’t wait to get away from. The more people who work as you do, the worse the shortage of physicians will become. That’s your choice. If you put yourself through medical school, then there’s a high likelihood that your education was heavily subsidized by federal and state dollars at a state university. The American people aren’t getting nearly the return on their investment that they were entitled to hope for. That again is your choice, not one that they had any say in. Sorry, but there really isn’t a lot of emotion for me in this. I do get weary of the whining about how hard physicians’ lives are, and wonder if they’re really blind to how the rest of the world lives. That was the impetus for this column. It really is the essence of privilege and entitlement. And I see in real life how women continue to “lean out”, perpetuating all the bad old reasons why women didn’t advance in the professional world: “They’ll get pregnant and either leave or just phone it in.” Hard to argue. Thank you for writing– Karen Sibert, MD

I guess to each their own–I would be sad if I spent the majority of my waking hours away from my child and taking care of my home and family to deal with an endless stream of entitled patients, administrators, endless paperwork, and prior auths, not to mention administrators who are now running the show and don’t even do any patient care. For me the opposite of work IS living-enjoying myself, family and friends and hobbies. No one on their death bed wishes they worked more. You can devote your whole life and career to your job in medicine, and guess what? When you leave out that door for the last time, things will run without you. Maybe if you are lucky and really devote your entire existence to your job you will get a conference room named after you. The way things are in the medical field today, we are ARE replaceable–in fact, I would bet that the government who you think we owe something to for subsidizing our education (with 6.5%+ interest rates on $200k+ loans and 50k a year for 60-80+ hour work weeks as residents-GEE, THANKS!) probably think that physicians in YOUR specialty are especially replaceable with CRNAs and AAs. The reality is, a huge percentage of females coming out of training agree with me, as are a growing number of males apparently from the article you quoted. If people choose NOT to “lean in” or to work part time and have work life balance, good for them! It’s their choice and should be respected.

Then I suggest Dr. Sibert YOU not sit in the rarefied confines of Ceders-Sinai, step up to the plate and see more patients yourself. I guarantee you I see many more patients than you do. What I don’t do is sit back in my ivory tower and sit in judgement of others. Do you see patients five days a week, take call every third weekend and every third night? When you do get back to me. Otherwise I find your comments appalling. Typical clueless academic.

Dear Joe, You don’t specify what field you’re in, but you perhaps don’t understand anesthesiology. I see a full day of cases, typically extending 10 hours and sometimes 12 hours. If you’re in primary care, no doubt you see more patients. I may do two cases, 5 hours each. By your standards, that’s two patients. Not really an apples to apples comparison. Cedars is very far from an academic ivory tower; my job is considered private practice with a teaching component. I took trauma call for 30 years, salvaging gun shot wounds (of which we have plenty in Los Angeles), bowel obstructions, and hip fractures, and have done my time in those trenches. Certainly you seem to judge others–we all do, whether we like to admit it. On a lighter note–the NHS seems to be trying the same sort of silliness as Stanford, offering Zumba as an alternative to inadequate pay: http://www.bbc.com/news/health-34120675 Best, Karen Sibert

Thank you for your post, Dr. Sibert. I think I see your point, and I do largely agree. Ideally work and life aren’t opposites or otherwise discordant but rather harmonies producing the same beautiful song. We can “live” good and productive lives *through* our “work,” not in spite of our work or as a corollary to our work. In this respect, older terms such as “vocation” or “profession” might be more appropriate to describe medicine. Medicine is a calling to which we respond from the depths of our being; a profession by which we speak words of life; a vocation in which we happily serve others, for we are tasked with one of the most noble pursuits of all: to heal the sick, to bandage the wounded, to strengthen the weak, to comfort the downtrodden, to bring life in the midst of death. Only the life of the physician, perhaps, is meet enough to begin to honor the work of the physician. At the same time, we live in less than ideal times. Today’s medical students and junior physicians are strapped with what seems to be near insurmountable debt before they even begin their careers. Not only medical school debt but undergraduate debt as well. They face a healthcare environment which more often than not seems to fight against them rather than for them or with them. Hospitals, corporations, and many others treat them with little if any respect, especially if they’re not in a patient-facing specialty. Moving them around the chess board like pawns. They’re asked to train ever longer and harder while regularly forgoing or at least for a time neglecting basic creature comforts (e.g. sleep, food, natural light). They’re surrounded by legal sharks always on the prowl to bite a pound of flesh from their loins. They’re often faced with overly entitled patients who demand perfection when the reality of caring for the diseased can’t help but be messy, chaotic, and (in a word) imperfect. And so on and so forth. Many junior physicians like myself and even many veteran physicians I’ve spoken with feel as if they’re like soldiers in the midst of an epic war. The tide of battle is turned heavily against them. They’re nearly surrounded. The enemy is attacking from what seems to be all sides. They’re asked to work miracles which, against all odds, they do, time and time again. They may tire or flag, they may sometimes complain, but in the end they bear with it and persevere with the hopes that things will improve. That fresh forces will come to their relief. That they’ll be rescued. But to date they wait. Speaking for myself, on the one hand, I realize I signed up for this life. Similar to the military, I signed up to serve in medicine. I regard it as both an honor and a privilege, but also a tremendous responsibility and duty. I don’t ask for or expect a life of ease and comfort. I aim to discharge my service as a physician to the best of my abilities. I aim to serve and serve well so that others may be helped. On the other hand, it would be unbearable for a human being to always have to live in a state of war. Never to have any respite. Forever serving one tour of duty after another. Even the best soldiers need some R&R. They need some time away from the war zone, and some time home with their loved ones. Not only does this help rejuvenate their bodies and souls, but it also helps them to remember what and who they’re fighting for – their families, their friends, their neighbors. It helps them to remember there’s a life outside the war. (As an aside, of course, no metaphor is perfect. I’ve drawn analogies between serving in medicine and serving in the military. But there are disanalogies as well. Chief of which is the fact that soldiers serve to defend by taking life, whereas physicians serve to help by healing life.) In short, while I am immensely proud to be a physician, which in turn I regard as a noble calling, and I’m prepared to live up to my calling as a physician to the utmost of my abilities, I likewise hope to see changes effected in the current medical climate so we physicians might have some relief as well. I do not ask or need a life of luxury and ease, but I wouldn’t mind some temporary respite so I can recover well enough to join the fight again.

Dear Patrick, Thank you for taking the time to write such a thoughtful reply. I can’t disagree with anything you say. All best wishes– Karen Sibert

Dr. Sibert – Your column on KevinMD and here is very disturbing. The mental health of physicians is at a crisis and your approach seems to be that this is just the way that it is, others who have gone before have suffered and that we should just appreciate what we have. I disagree. As a primary care physician seeing 28 patients a day I feel that I am serving the community on the front lines. The pay is not adequate, the hours are long, the clinical support is limited and the administrative support is neglectful. 6 physicians have left from this office this year. I encourage this facility to begin a wellness program to deal with the stresses of the day including demanding patients that are sometimes physically threatening when they don’t get what they deem is necessary pain control. As a female professional I am “leaning in”. I am expecting twins in Jan and will be working and taking the very minimal time away from work out of necessity. My student loans will not repay themselves despite the 4 scholarships in medical school. I am really struck by your lack of compassion for others in the medical profession. Your disdain and hatred for your colleagues is palpable. This is not going to lead us to a solution for this healthcare train wreck. 300-400 physicians commit suicide yearly. That is an entire medical school class. As an anesthesiologist, I would think that you have perhaps heard that anesthesiologists are at particular risk. I really wish that you would use this forum for a more positive goal and to shed light on facts. I think there are enough problems to tackle (EMR, government regulations and meaningful use, frivolous malpractice). Do we need to fight each other as well or pit specialists against primary care (again)? Physicians in my office make $85/hour gross. The attorneys reviewing the employment contract make $650/hour. There is something really wrong here. Also, we live in the most expensive city in the nation for housing. I’m shocked that you think all physicians who are concerned about burnout are “privileged” and “entitled”. Wow. Would you say this to the surviving parents/spouses of physicians who have committed suicide? Will my writing this even make any difference? I’m so disappointed that you chose this issue to dig your heels into. Terri Bowland, DO

This is an email I received from Zanetta, the surgical technician, after this column was published. She is really the inspiration for it. Nowhere in my piece do I “bash” primary care physicians, or anyone else for that matter, except for people who complain when they have so much that others around them do not. Here’s what Zanetta had to say: “Dr. Sibert! Words can’t express how TRULY honored I am that you feel highly enough of me to mention me in your article. You have touched me darn near to tears! That was so kind of you. I had no idea that you even recognized me in such a way to realize the struggles ( along with joys) that I face with being a single working mom. Thank you for that! Really….thank you! I love you! ?

Zanetta”

Dr. Sibert- As a current senior resident looking forward to my chief resident next year, I was profoundly disturbed by your article, in particular that it found its way into wider circulation via KevinMD. I would hate for any current resident, in any field, who is experiencing burnout to have read your piece. It represents a particular type of fantasy, retrograde approach to how physicians work and live. 1) Burnout is a real phenomenon. Having experienced it myself during my training, it is a profoundly troubling feeling. To feel as if your work has no meaning is as dislocating a sensation as can be, especially in a career that we both agree to be a life calling, not a vocation. I don’t know how you can argue that burnout, as it is defined in the medical literature, is not a real phenomenon that requires more intervention and thoughtfulness than a cursory “toughen up.” 2) The Stanford program you mock was started in the name of an accomplished surgical resident who committed suicide shortly after starting his surgical fellowship. Whether you meant to or not this comes across as immensely disrespectful. 3) I’m sorry, I’m sure your trauma calls were long and stressful, but as an anesthesiologist you are shielded from many of the most difficult patient encounters in medicine, you haven’t followed patients over time, and your experience of death and dying is quite different than mine (as an internist) or say, a surgeon’s. I’m not implying you don’t care, but I submit that a large part of my burnout was fueled by watching young adults succumb to horrible illnesses I was powerless to cure. We offer comfort and solace, but this taxes our own souls. Asking for space to discuss these issues is not weakness or whining, it is vital. 4) I watched my dad work long hours, work overtime, in a blue collar job, worked much of his life away. He didn’t complain much, I really don’t see what that has to do with my burnout experience. I appreciate his sacrifices, as he appreciates mine now as he deals with his own serious illness. I would argue the comparison is a straw man: the jobs aren’t the same, the demands aren’t the same, and the emotional tolls are different. 5) Not sure what you meant by “first world problem,” I’m sure doctors working in the “third world” get burned out too. Much like your famous op-ed in the NYT a few years ago, I don’t think your writing here is terribly constructive. The residents and interns I work with now deserve better from my colleagues and me than “toughen up” and that they will make a lot of money in their life so they shouldn’t complain about work. I’m proud of the work we do, and I am fulfilled in my work. That doesn’t mean I don’t feel run down or beat down by my job. Those are normal human emotions, and physicians who engage with patients across time, in health and in serious illness, and ultimately in death and dying, we have to care for ourselves to better care for our patients. Unless you want to quit anesthesia and help us out on the wards and in the clinics. Best, Chris Vercammen, MD

UCSF internal medicine resident