Provider Engagement and Wilderness Medicine

What I want to speak for is not so much the wilderness uses, valuable as those are, but the wilderness idea, which is a resource in itself. Being an intangible and spiritual resource, it will seem mystical to the practical minded—but then anything that cannot be moved by a bulldozer is likely to seem mystical to them….It is good for us when we are young, because of the incomparable sanity it can bring briefly, as vacation and rest, into our insane lives. It is important to us when we are old simply because it is there—important, that is, simply as an idea. ¹

Wallace Stegner

Wilderness Letter ¹

December 3, 1960

Like many emergency physicians, my interests and experiences were wide ranging. Prior to matriculating in medical school, I was a graduate student in history; worked in construction (demolition, cabinet shop); ran electrophoresis gels in a virology lab; and wrote health care manuals for a nonprofit. Each summer I spent a few weeks canoeing the back country in Quetico Provincial Park, or the Allagash in Maine, or climbing in the Sierras. The dilettantism of my early 20s succumbed to the rigor of medical school and over the years I attempted to stay within the white lines established by organized medicine. While I continued to be amazed and intellectually challenged by the range and variation of illness in my fellow humans, I was not prepared for the feelings of exhaustion and cynicism that slowly crept into my consciousness after 20 + years of practice. I was burned out.

I did not have the vocabulary to describe my sense of unease and apprehension. I was unfamiliar with the literature on burnout, which, at the time, was in its infancy. It was a topic rarely raised and considered more of a reflection on an individual, rather than on the system. Times have changed and there has been an explosion of literature on the topic. A recent Medline literature search using the keywords “physician burnout” and “professional burnout” returned over 17,000 hits.

This is not surprising. In the United States over the past decade the practice of medicine has been transformed on both an individual and systems level. Catalyzed by the pandemic, over 140,000 healthcare workers including physicians (71,000), nurse practitioners (34,000), physician assistants (13,000), and other healthcare workers left the workforce between 2021-22. ² Burnout among emergency physicians reached > 60% in 2022, with hospitalists, family medicine physicians, internal medicine, and ob/gyn close behind.^3,4,5 In my field of emergency medicine many physicians have left the workforce. This is compounded by the rapid attrition of the female workforce—woman leave the EM workforce almost 12 years younger than male emergency physicians. ⁶ Nurses and APPs are also caught in the crossfire. Over 40% of nurses and one-third of PAs met criteria for burnout.^7,8 Burnout has created additional challenges for international health systems, as well.^9,10,11,12

While there are numerous reasons for burnout, disengagement likely has had an outsized impact. In the United States, physician practice patterns have changed as hospitals have evolved from local individual facilities to large systems with corporate governance. In 2012, 60% of practices in the United States were physician-owned, and < 6% of physicians were direct hospital employees. ¹³ Over the course of one decade hospital systems now dominate the industry and almost 75% of physicians are employees of hospitals, health systems, and other corporate entities.^13,14,15,16 The allure and benefit of the corporate health/physician bargain, in which providers could operate without administrative red tape and the financial stressors of practice management, has vanished. Provider payments have not kept pace with inflation and physicians spend almost 2 hours on administrative tasks and electronic health records for every hour of patient care. ¹⁷ Antidotes to burnout—wellness committees—have metastasized throughout academic healthcare systems. Yet, it seems as if even their existence, while established with the best of intentions, is an additional manifestation of practitioner’s loss of autonomy and the corporatization plaguing healthcare.

Shanafelt and others have addressed burnout and promulgated organizational strategies designed to promote physician well-being. ¹⁸ Individual strategies have also been suggested and have demonstrated some, albeit, limited success.^19,20 As a late career physician who has had only moderate success in navigating the Scylla of corporate healthcare and the Charybdis of burnout, I often ponder the question as to why I continue to enjoy the practice of medicine. Without question, medicine has become part of my identity, and is something I am not ready to surrender. I enjoy patient care, the exchange of ideas, and continuous learning. However, none of us are one-dimensional and there are other strategies that stave off burnout and keep us engaged.

On an individual level, my family shares an appetite for habits I developed years ago in Quetico, the Allagash, and the Sierras, and an appreciation of Stegner’s “intangible and spiritual resource.” This resource renews and revitalizes and I am grateful those closest to me share my passion. At a professional level, active membership in medical societies provides a venue for collaborative learning and combats the isolation contributing to burnout. ²¹ I have continued to reflect on the remarkable multigenerational energy and focus of last summer’s WMS meeting, and look forward to the July 2024 gathering. I have been buoyed by burgeoning student and resident interest groups, and I am invigorated by the many unique submissions to our journal. As an editor and member of the wilderness medicine community, I have joined others with a common frame of reference. Together, we can advance our field as well as create a bulwark against the troubling, corrosive impact of burnout among health professionals.