Healthcare Is Becoming More Disconnected The hustle and bustle of the holidays and the accompanying get-togethers and social obligations—among family, friends, and colleagues—has come to an end. A new year means time to get back to work and, often for physicians, picking up old work habits that tend to isolate them from others. By their nature, humans are social creatures. Although each of us needs periodic respites of solitude, there is an important difference between being alone and being lonely. For those who practice medicine, this distinction has become much more visceral in recent years. There are many reasons that people choose to practice clinical medicine, but those reasons are often based in an essential priority of connecting with other people and helping them. The relentless corporate trend of fragmenting healthcare delivery has been exerting an inexorable pressure on the soul of the physician. In my practice lifetime, I've seen the dissolution of the connected professional community. My partner and I still do our very best to be fully engaged as physicians in the office and the hospital, and with our families, and the community. It's incredibly challenging to balance. Indeed, while we're doing much more now to communicate and collaborate together, in the recent past it was not uncommon for us to go an entire week in the office without laying eyes on each other. When a physician doesn't happen across their partner, or is too overburdened with scheduling and documentation requirements to go to the hospital or attend a professional or social gathering, then what is the route of professional connectivity? As John J. Frey 3rd, MD,[1] wrote recently in a must-read treatise, such changes "have led to an increasing sense of professional loneliness that not only threatens the quality of clinical care by replacing personal discussions about patients but also poses risks to physician personal and professional wellbeing." Dr Frey's recitation of how collegial and "fun" medical school and training, and even lunches or quick visits to the doctor's lounge/dining room, used to be is spot on. This experience may be utterly alien to those who have trained under "work hour restrictions," which have forced young colleagues to physically leave the training facility by a set time or face censure. What Contributes to Medical Isolation? Furthermore, Dr Frey is correct to explain, "Today, lunches are solitary, eaten at desks from plastic containers from home or takeout from local restaurants while catching up on email, writing charts before the afternoon begins, or answering online patient inquiries. Even in common spaces and nurses' stations, everyone sits silently in front of a computer screen."[1] It probably doesn't help that the last couple of generations largely have not been "joiners." There are still examples of medical school alumni groups and attendees at medical organization meetings who maintain strong social bonds through such activities, but these appear to be exceptions to this rule. So, if physicians are not connected to other physicians at work, or in professional organizations, where do they turn for their outlet? As women entered the physician workforce, the rates of dual-physician marriages naturally increased as well. Certainly, there are many potential positives to being married to a partner who understands the required journey to becoming a physician. However, it should not be assumed that these relationships resolve issues of professional loneliness. Differences in medical/surgical specialties between spouses can be very substantive. Indeed, there can even be a "leave work at work" mantra for the couple which, while creating a haven from work's pressures in the home, does not provide complete respite, because some pains do not diminish in silence. Compounding this, the requirements to complete medical documentation often push into the late hours of the night, negating the potential for family and spouse interactions. The electronic health record is a potent and effective isolating force in today's physician's life. When one doesn't encounter colleagues, whether in a segmented large medical setting or an isolated rural practice; doesn't have communal professional outlets; and doesn't collaborate on the stressors with a spouse or is proactively isolated from one's spouse by documentation requirements, being a physician in today's world begins to feel particularly lonely. Seeking Solutions to End Physician Loneliness There is, of course, for those of us engaged in continuity of care, the interactions with patients, many of whom are friends who have elected to become patients or patients who become friends over time. While the value of these relationships cannot be overemphasized, it is also true that it is a relationship of uneven sharing. Even once the medical care aspects of an interaction are concluded, there are appropriate and necessary limits which a physician should not (and must not) overstep with a patient because of the power disparities, differences in privacy standards for a patient/friend, and so forth. Consequently, there's an inherent inhibitory effect on the connective healing of such relationships for physicians, in particular. This leads some physicians to nonmedical online forums and other online communities. The anonymity of the Internet can free a physician in some unique ways, but of course compels the physician to practice identity concealment. There is no need to assume additional potential medicolegal liability from providing online medical advice. Others online, knowing that "user123" is a physician, will also probably influence how they perceive and treat that person. As a friend recently said to me, "Doctors need friends who aren't doctors." They also need time to not be doctors during their week. Balancing this set of "imaginary friends" against real-world challenges and obligations can be detrimentally difficult for many. There were assertions made that the coming of the Internet age and the dawning of robust personal mobile technology would bring us all together, help us communicate, and help us connect. Certainly, at times that is true. Ultimately, we have learned as a society that the Apple device (or Android, et cetera) on your hip doesn't make you happy. Again, the limitations of our conversational speech in general and in "smart" device communication does not allow us to "see" each other. It is too easy to put up a false face, to hide our feelings, have our posts go unanswered, or to be simply misunderstood. Even the purveyors of such technology have restricted their own children from using it.[2] Loneliness Can Be Lethal The consequences of loneliness and the pitfalls of navigating the complex interplay of relationships, emotions and loneliness are too great to ignore. Loneliness is lethal, according to a 2013 article in The New Republic.[3] The psychological definition of loneliness hasn't changed much since [20th century therapist Frieda] Fromm-Reichmann laid it out. "Real loneliness," as she called it, is not what the philosopher Søren Kierkegaard characterized as the "shut-upness" and solitariness of the civilized. Nor is "real loneliness" the happy solitude of the productive artist or the passing irritation of being cooped up with the flu while all your friends go off on some adventure. It's not being dissatisfied with your companion of the moment—your friend or lover or even spouse—unless you chronically find yourself in that situation, in which case you may in fact be a lonely person. Fromm-Reichmann even distinguished "real loneliness" from mourning, since the well-adjusted eventually get over that, and from depression, which may be a symptom of loneliness but is rarely the cause. Loneliness, she said—and this will surprise no one—is the want of intimacy. The modern psychological study of loneliness is often traced back to Frieda Fromm-Reichmann. She estimated that loneliness lay at the heart of nearly all mental illness and that the lonely person was just about the most terrifying spectacle in the world. As the neurobiology of loneliness has been deciphered, her assertions have been confirmed. Loneliness has been shown to disrupt proper hormonal signals, reregulate the expression of behavioral genes, and further distort the workings of our mortal coils. Last year, loneliness was reported as a potentially bigger health risk than smoking or obesity.[4] Disease associations have been found between loneliness and "Alzheimer's, obesity, diabetes, high blood pressure, heart disease, neurodegenerative diseases, and even cancer—tumors can metastasize faster in lonely people."[3] A key part of feeling lonely is feeling rejected, and that, it turns out, is the most damaging part.[3] Overcoming Rejections, Regaining Connections The life of a modern American physician is replete with rejections. There are the rejections of orders via incessant prior authorization criteria, some of which are insurmountable; of nonadherence and no-shows; and of the "Dr Google" experts who, perhaps unintentionally, repudiate the entirety of the physician's training, education, and experience on the basis of a self-fulfilling, nonacademic Internet search, as well as the omnipresent sense that harder, faster, quicker is never going to be enough. For general internists, there can be the rejection of their entire life's calling, as generations of medical students have rejected this career path, thanks to the draconian and vampiric effects of the American Board of Internal Medicine's certification policies, and the repudiation of the value of the training and experience of the "doctor's doctor" by the government and private payers. To practice in the backdrop of these rejections in a healthcare system that has isolated us very effectively should be of fundamental concern to the nation, as it continues to face a physician shortfall, particularly in primary care. The remedy for such stressors and challenges is, rather simply, to congregate, to bond, to not be alone, to not be lonely. One would wonder whether there is not a design flaw for stress to affect our bodies and longevity thus. The answer, though, is more sublime. The remedy for such stressors and challenges is, rather simply, to congregate, to bond, to not be alone, to not be lonely. The chronic provocations of the broken-down healthcare "delivery system" relegates physicians into a chronic and unsustainable fight-or-flight mode. This, along with sleep deprivation (by quantity and quality) and myriad deleterious effects (including those on systemic vascular resistance and tissue inflammation, among others) exact a significant toll on those who have committed their lives to being of service to others. The tragic nature of these circumstances is not that physicians who have assumed these service roles do not live trouble-free lives. Rather, it is that people of goodwill, great intellect, and compassion are not perceived by society and those around them and, further, that these consequences curtail the longevity and effectiveness of those healthcare providers, who are a critically limited resource to our society today. One of the chief limitations of our society, and our language, is that we recognize each other but we do not "see" each other. In parting, we may say to others that we will "see them," but we don't "see." This realization was well represented in the interactions of the Na'vi in the movie Avatar. Neytiri says, "I see you"—the traditional Na'vi greeting meaning "I see who you truly are." There was an interesting effect in the wake of that movie of a "blue funk," of heightened pain caused by the sense of human loneliness standing in stark, 3D contrast to the idealized relationships portrayed on the silver screen.[5] We can't hope to replicate that world in this one, but we can surely do better than we are doing currently in this one. References Frey JJ 3rd. Professional loneliness and the loss of the doctors' dining room. Ann Fam Med. 2018;16:461-463. Source Accessed December 13, 2018. McCartney J. Tech gurus don't let their kids have smartphones. Here's why. The Spectator. September 22, 2018. Source Accessed December 13, 2018. Shulevitz J. The lethality of loneliness. The New Republic. May 13, 2013. Source Accessed December 13, 2018. Porter B. Loneliness might be a bigger health risk than smoking or obesity. Forbes. January 18, 2017. Source Accessed December 13, 2018. Piazza J. Audiences experience 'Avatar' blues. CNN. January 11, 2010. Source Accessed December 13, 2018. Source
