Medical culture: How it affects general practitioners’ wellbeing and what needs to change

When students enter medical school, they are psychologically quite healthy. Compared with their non-medical peers, they show lower burnout and depression and higher quality of life, even after adjusting for sociodemographic factors.¹ By the point of internship and specialty training, they experience higher burnout and depression symptoms, greater fatigue and worse quality of life than general population samples.² Concerningly, these disparities persist after training, with doctors reporting higher burnout levels and greater dissatisfaction with their work–life balance when compared with the general population.³ There are many complex and interacting causes for poor wellbeing among doctors at organisational and systemic levels; however, a broader contributor is the culture of medicine.

In this article, I will first outline what a professional culture is, then highlight two intertwined elements of medical culture that foster poor wellbeing among doctors – perfectionism and self-neglect. I will conclude with suggestions for how these issues can be effectively managed. These perspectives are offered from an outsider to medicine, but someone who has been working in this area for some years. My hope is these views are illuminating and invite reflection.

What is a professional culture?

A professional culture comprises tangible and intangible qualities of a professional group, including beliefs, values and behaviours. Boutin-Foster et al highlight several of these elements of medical culture, including wearing of the ‘white coat’, the way in which doctors speak (eg use of acronyms or medical jargon) and a medicalised view of disease processes.⁴ At a deeper level sit the values inherent in medical culture, such as altruism, excellence, honesty and empathy. These values are embedded within the way doctors act and the structural and policy establishment of medicine. It is through the manifestations of these values, termed the ‘hidden curriculum’,⁵ that what it means to be a doctor is modelled to trainees and reinforced to experienced doctors. As a whole, medical culture is functional; it creates a common identity that unifies the profession and sets standards for appropriate behaviour. However, there are elements of medical culture that are hazardous to doctors’ wellbeing.⁶

Perfectionism and invulnerability

Medicine demands excellence. As a high-stakes profession with a large degree of responsibility, an expectation for excellence is sensible and commensurate with the public’s trust in the profession. However, as so eloquently articulated by one medical student, ‘Excellence is attainable and sustainable. Perfectionism is neither of the two’.⁷ Concerningly, medicine’s standards have shifted from excellence to perfection, breeding an intolerance of mistakes. This has meant doctors are expected to be ‘invincible’ – infallible professionals who are impervious to physical and psychological difficulties.⁸ The effects of this are wide-ranging and deleterious. For instance, this expectation means mistakes are viewed as the failure of an individual rather than a combination of individual and systemic factors.⁸ Furthermore, there is no room for doctors’ health to be anything less than optimal or for doctors to not be ‘in control’ of their lives. This prevents appropriate vulnerability. Indeed, it reinforces doctors’ tendencies to self-treat rather than seek health services,⁹ in turn creating a self-perpetuating cycle. The result is constantly being surrounded by colleagues who appear to be perfectly fine, fuelling self-doubt and inferiority.¹⁰ When a doctor does experience health difficulties, the experience can be stigmatising and ostracising.¹¹ Although the drive for excellence is commendable, it has produced an unhealthy level of perfectionism and invincibility that poses a considerable risk to doctors’ health. Doctors are humans too, but this fact is rejected by medical culture.

Self-neglect

A further prized value of medicine is that of altruism or service – a doctor’s professional purpose is to help others. Again, this is a noble value and one that should indeed be prized; however, this easily can – and has – become an expectation of self-sacrifice. Doctors will work excessive hours, even when they are ill.⁸ Likewise, doctors neglect their nutrition and hydration needs when they are working, sometimes to the point of dehydration after their shifts.¹² These observed behaviours reflect psychological processes. Doctors report significantly lower levels of self-valuation (ie the extent to which they prioritise their needs) when compared with the general population. In one study, doctors were 50% more likely than a non-medical sample to frequently respond to their mistakes with self-condemnation rather than as opportunities for growth, and 3.5-fold as likely to often or always defer seeking health services because of time pressure.¹³ Similarly, medical students report feeling guilty when they observe their peers working or studying when they are relaxing,¹⁴ highlighting the social pressure at play in these beliefs. Notably, although doctors display significantly higher burnout than general working populations,³ these differences disappear after controlling for differences in self-valuation.¹³ Thus, the drive for altruism in medicine appears to have reached a level of detrimental self-sacrifice.

How can we reform medical culture?

The purpose of this article is not to demonise medical culture. The values of medicine are noble and deserve preservation. Rather, in this article, I seek to highlight how these values have been taken to their extreme and the resultant deleterious effects. Medical culture does not need re-inventing, but careful evaluation and deliberate efforts are required to rebalance its values with the wellbeing of its community. This is no small undertaking, and cultural change is a glacial, complex process.¹⁵ Nonetheless, cultural reform is necessary to ensure the sustainability of the medical profession; the wellbeing crisis facing medicine shows that inaction is not an option.¹⁶

What, then, can be done by the general practitioner (GP) on the ground? A practical step that can be taken to rebalance these values is practising self-compassion. Self-compassion comprises three aspects of responding to one’s suffering: (1) being kind to oneself (rather than harshly judging oneself); (2) acknowledging the universality of suffering (rather than viewing one’s experience as isolating); and (3) being mindful of one’s suffering (rather than excessively identifying with or avoiding it).¹⁷ This is a particularly useful antidote to the two examples above (ie perfectionistic invulnerability and excessive self-sacrifice). By definition, treating oneself kindly acknowledges the importance of attending to one’s own needs and thereby counters the emphasis on self-sacrifice. Similarly, it invites creating more realistic self-expectations, countering perfectionistic strivings. Recognising the universality of suffering is at odds with isolation and stigma of ill-being, thereby creating space for appropriate vulnerability within medical spheres. The evidence also supports these assertions; self-compassion has been found to reduce self-criticism,^18,19 suggesting it is an effective approach to combatting perfectionism and offsetting the guilt from prioritising one’s own needs evoked by self-sacrificial norm.

Practically, using self-compassion to reform medical culture requires behaviour change. Culture is learnt through observation and fundamentally is a process of ‘fitting in’ with others. Accordingly, as individuals start to change their behaviours, this inherently will produce cultural change, albeit gradually. This is exemplified clearly in the case of trainees’ professional identity formation, which is heavily influenced by how those around them role model what it means to be a doctor.²⁰ Starting to practise self-compassion will sow the seeds for behaviour that is still congruent with the values of medicine, but in a more sustainable way. This could take the form of making a concerted effort to take a lunch break or keeping a drink bottle at your desk. It could be that rather than criticising yourself over a near miss, you use such experiences as an opportunity for learning and growth. A more substantial shift could be appropriate self-disclosure to colleagues or a registrar about your experiences of general practice; for example, discussing what you found difficult about adjusting from the hospital system. The emphasis here is on appropriate disclosure and so need not be highly personal or on topics that you are uncomfortable sharing. Rather, the aim is to normalise the struggles of being a doctor with one another, thereby building psychological safety. Kristen Neff, a pioneer in the self-compassion literature, has a website with a variety of resources to support you in your practice of self-compassion (https://self-compassion.org/self-compassion-practices).

Conclusion

The fundamental principles of medical culture are sound; however, through a myriad of factors, they have been taken to the extreme such that they are hazardous to doctors’ health. In particular, excellence has become unrelenting perfectionism, while altruism has morphed into excessive self-sacrifice. Medical culture needs reform to reconnect with its true core values. Although this is a major undertaking that requires considerable structural and policy changes, it also requires input from individual doctors. GPs have a role to play, especially those involved in educating trainees. Simple steps of engendering greater self-compassion will not only support your own wellbeing, but also initiate the cultural reform medicine so desperately needs to ensure a sustainable profession that can live up to its ideals.

Key points

• A core contributor to the wellbeing epidemic facing doctors is issues with medical culture.
• The core values of medical culture are sound and noble but have been taken to the extreme.
• Excellence has become unrelenting perfectionism and resulted in a lack of psychological safety.
• Altruism has morphed into excessive self-sacrifice, resulting in doctors neglecting their own needs.
• Engendering greater self-compassion represents an effective antidote to rebalance medical culture and simultaneously support one’s own wellbeing.