What Are Doctors For? A Call for Compassion-Based Metrics as a Measure of Physician Value
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* Timothy Aaron Zeller
* Parker A. Rhoden
* Catherine Florio Pipas

## Abstract

Modern measures of physician value are couched in terms of productivity, volume, finance, outcomes, cure rates, and acquisition of an increasingly vast knowledge base. This inherently feeds burnout and imposter syndrome as physicians experience an inability to measure up to unrealistic standards set externally and perceived internally. Ancient and modern wisdom suggests that where populations fail to flourish, at root is a failure to grasp a vision or true purpose. Traditional philosophical conceptions of a physician’s purpose center around compassion, empathy, and humanism, which are a key to thwarting burnout and recovering professional satisfaction. New compassion-based metrics are urgently needed and will positively impact physician well-being and improve population health.

Key words:
*   performance metrics
*   physician wellbeing
*   burnout
*   imposter syndrome
*   empathy
*   purpose
*   joy in practice

## WHAT ARE DOCTORS FOR? (AND THE IMPORTANCE OF MEASURING IT)

Vision is critical to directing efforts, and metrics are critical to ensuring that a vision is achieved. What we measure tells us what we value, and measurement aligned to vision drives meaningful outcomes and optimal performance. In this reflection we consider measurement in light of the question, “What are doctors for?” The answer is not just to cure, to heal, or to be knowledgeable about diseases, diagnosis, and treatment, but also to care. When a physician’s value is incorrectly calculated solely based on performance metrics, burnout is likely to follow. If we agree that a physician’s primary value lies in caring, compassion, and empathy, we must prioritize measuring it, or risk the burnout that can develop when a physician’s value is incorrectly calculated solely based on performance metrics. We lay out a vision for much-needed compassion-based metrics and call on health care systems to envision compassion-based metrics that optimally align with what society and physicians say they value in the physician role.

### Historical and Philosophical Foundations of Physician Purpose

Ancient wisdom found in philosophical literature suggests “Where there is no vision, the people perish,”1 implying that a certain *raison d’etre* is vital for human flourishing, and that without it, hopelessness and despair are the rule. Wendell Berry, heralded as one of the greatest American visionaries of the 20th century,2 agreed with this assessment in his writings. His essay “What Are People For?” described the current plight of the American worker and farmer with surprising accuracy given its timing (1990).3 He predicted that without a proper valuation of the true worth of an individual by corporations and policy makers, people and rural communities would atrophy—in other words, without a vision, they would perish.

Berry’s prediction rings true among the physician workforce—an absence of flourishing is epidemic. Studies show that burnout affects up to 51% of the physician workforce.4-8 The condition is recognized as an occupational hazard and public health crisis.9 Detailed prescriptive advice exists for mitigating its effects on the health workforce,10 with numerous contributing factors and etiologies having been researched.8,11,12 The origins of burnout and related conditions of workforce disengagement, however, are not simply due to the COVID-19 pandemic, electronic health records, or lack of resilience. Rather, we have failed to properly value (measure) a physician’s professional purpose and their humanistic contributions.13 In the search for a solution to a problem, the way one frames the question predetermines the range of answers one can conceive in response.14 So, modifying Berry’s question, “What are doctors for?” we ask, how does society assess their contribution and measure their performance? What metrics would be most consistent with the true purpose physicians are called to fulfill?

Historically, physicians were teachers, counselors, listeners, and most of all they provided care (empathy, compassion), often out of a spirit of altruism, humanism, and a sense of vocation.15-17 This recognition generates a hypothesis: If a physician’s true value is inadequately assessed, they risk experiencing burnout and they and their patients’ well-being suffers. Conversely, if a physician’s true value is measured based on their capacity to care, they can begin to rediscover joy in their work and they and their patients can thrive.18,19

### The Effects of Compassion on Patient Care and Burnout

Physician burnout is linked to many adverse outcomes including patient dissatisfaction, increased medical errors, poor quality of care delivery, and decreased ability for physicians to express empathy.20-24 Burnout, with its depersonalization and compassion fatigue components, has been called the antithesis of empathy.25 Empathy, on the other hand, triggers oxytocin release and improves generosity.26 Empathy training has been shown to improve symptoms of burnout among primary care physicians.21 A study of medical school curricula tied increases in empathy to concomitant decreases in burnout scores.27 Research into rehumanization has suggested empathy as an antidote to the dehumanization and depersonalization wiring that can occur in the human brain.28 In a study of orthopedic patients, 65% of patient satisfaction was attributable to physician empathy,29 and physician empathy was strongly correlated with patient satisfaction in a study of pain clinic patients.30 Finally, a systematic review in Britain found that empathy is of “unquestionable importance in general practice outcomes.”31 In other words, people may forget what their physician said or did, but they will never forget how they made them feel. It is vitally important that physicians be empowered to disconnect their intrinsic professional identities from numbers and recognize that their true impact is grounded in the cultivation of kindness and trust. Living into this purpose unleashes a powerful chain reaction.15

### The Consequences of Not Measuring Compassion

Physicians were not expected to excel at speed of care or recognized for the volume of decisions made in a short period of time until the 20th century. Before that, curative therapies such as antibiotics were unheard of,17,32 and physicians often had no recourse other than to be “compassionate witnesses.”33 Performance measurement is a modern development of the health care industry focused on objectively assessing outcomes and productivity; yet subjective measurement of the human component of doctoring is noticeably absent from our system. Currently, most primary care physician performance measures focus on aspects such as quality data, patient experience, individual productivity, practice financial performance, and practice efficiency.34 While these measures guide outcomes associated with the physician’s performance, they can contribute to burnout and the imposter syndrome.35,36 Imposter syndrome is defined as feelings of uncertainty, inadequacy, and being undeserving of one’s achievements despite evidence to the contrary. Treatments include advice on reorientation of self-worth to something other than external performance and accepting one’s humanity (accepting “good enough” instead of perfection),37 and implicitly link imposter syndrome to a meritocratic or technocratic definition of a physician’s purpose and the compunction to know it all and cure it all. Population health and productivity metrics, while necessary measurements for health system outcomes, are poor measures of a physician’s full performance and can lead to feelings of inadequacy and loss of purpose.38 Efforts to avert burnout and imposter syndrome in physicians would benefit from a new paradigm for metrics based on traditional understandings of physicians’ value—their ability to compassionately care.39,40

### A New Model for Measuring Care

We return to the foundational, reframed question: “What are doctors for?” They are a cornerstone of the health care system, serving to diagnose, treat, educate, and care for those in need. While diagnosis and treatment are being measured, however, care and compassion are not. Imagine for a moment a future where health care quality is measured not only by the diagnosis and treatment of illness, but also by the humanism of physicians and the benefits that humanism provides to society—the “compassionate witnessing” that patients remember most. In conclusion, we propose the creation of a physician value metric which comprehensively assesses a physician’s compassion, drawing input from patients, staff, peers, and physicians themselves. Such a measure would be expected to improve patient satisfaction, patient outcomes, and physician well-being based on the results of the studies summarized above. May this reflection be a call to a crucial pivot in our battle against burnout in the physician workforce, and a necessary reimagination of measures of physician value as health systems prioritize well-being for all.41

## Footnotes

*   Conflicts of interest: authors report none.

*   [Read or post commentaries in response to this article](https://www.annfammed.org/content/22/4/352/tab-e-letters).

*   Received for publication July 31, 2023.
*   Revision received March 5, 2024.
*   Accepted for publication March 11, 2024.


*   © 2024 Annals of Family Medicine, Inc.

## References

1.  1.The Proverbs of Solomon. 900 BCE; 29: 18.
    
    

2.  2.Smith P. Responsibly at home in the Great Economy. The Christian Science Monitor. Published Jul 3, 1987. [https://www.csmonitor.com/1987/0703/bhome.html](https://www.csmonitor.com/1987/0703/bhome.html)
    
    

3.  3.Berry W. What Are People For?: Essays by Wendell Berry. North Point Press; 1990.
    
    

4.  4.National Academies of Sciences, Engineering, and Medicine. National Plan for Health Workforce Well-Being. National Academies Press; 2022.
    
    

5.  5.Linzer M, Jin JO, Shah P, et al. Trends in clinician burnout with associated mitigating and aggravating factors during the COVID-19 pandemic. JAMA Health Forum. 2022; 3(11): e224163. doi:10.1001/jamahealthforum.2022.4163
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1001/jamahealthforum.2022.4163&link_type=DOI) 

6.  6.Kane L. I cry but no one cares: physician burnout & depression report 2023. Medscape. Published Jan 27, 2023. [https://www.medscape.com/slideshow/2023-lifestyle-burnout-6016058?faf=1#1](https://www.medscape.com/slideshow/2023-lifestyle-burnout-6016058?faf=1#1)
    
    

7.  7.Aiken LH, Lasater KB, Sloane DM, et al; US Clinician Wellbeing Study Consortium. Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. JAMA Health Forum. 2023; 4(7): e231809. doi:10.1001/jamahealthforum.2023.1809
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1001/jamahealthforum.2023.1809&link_type=DOI) 

8.  8.Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clin Proc. 2022; 97(12): 2248-2258. doi:10.1016/j.mayocp.2022.09.002
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/j.mayocp.2022.09.002&link_type=DOI) 

9.  9.World Health Organization. Burn-out an occupational phenomenon: International Classification of Diseases. Accessed July 8, 2023. [https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases](https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases)
    
    

10. 10.National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies Press; 2019.
    
    

11. 11.Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc. 2019; 94(9): 1681-1694. doi:10.1016/j.mayocp.2018.10.023
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/j.mayocp.2018.10.023&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=30803733&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 

12. 12.Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012; 172(18): 1377-1385. doi:10.1001/archinternmed.2012.3199
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1001/archinternmed.2012.3199&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=22911330&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000309540500003&link_type=ISI) 

13. 13.Kerr S. On the folly of rewarding a, while hoping for b. Acad Manage Exec. 1995; 9(1): 7-14.
    
    

14. 14.Friedman EH. A Failure Of Nerve: Leadership in the Age of the Quick Fix. Church Publishing; 2017.
    
    

15. 15.Zeller TA. Don’t take it lying down-vocation as an antidote to weltschmerz. J Grad Med Educ. 2022; 14(3): 267-269. doi:10.4300/JGME-D-21-01132.1
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.4300/JGME-D-21-01132.1&link_type=DOI) 

16. 16.Laurel SJD. Medicine as a sacred vocation. Proc (Bayl Univ Med Cent). 2018; 31(1): 126-131. doi:10.1080/08998280.2017.1400318
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1080/08998280.2017.1400318&link_type=DOI) 

17. 17.Pusey WA. A Doctor of the 1870’s and 80’s. Charles C. Thomas; 1932.
    
    

18. 18.Lebow R, Spitzer R. Accountability: Freedom and Responsibility Without Control. Berrett-Koehler Publishers, 2002.
    
    

19. 19.Bakke D. Joy at Work: A Revolutionary Approach to Fun on the Job. Pear Press; 2006.
    
    

20. 20.Haas JS, Cook EF, Puopolo AL, Burstin HR, Cleary PD, Brennan TA. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000; 15(2): 122-128. doi:10.1046/j.1525-1497.2000.02219.x
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1046/j.1525-1497.2000.02219.x&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=10672116&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000085296400008&link_type=ISI) 

21. 21.Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009; 302(12): 1284-1293. doi:10.1001/jama.2009.1384
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1001/jama.2009.1384&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=19773563&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000270026000010&link_type=ISI) 

22. 22.Crane M. Why burned-out doctors get sued more often. Med Econ. 1998; 75(10): 210-212, 215-218.
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=10179678&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 

23. 23.Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003; 114(6): 513-519. doi:10.1016/s0002-9343(03)00117-7
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/S0002-9343(03)00117-7&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=12727590&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000182551900017&link_type=ISI) 

24. 24.Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005; 20(7): 559-564. doi:10.1111/j.1525-1497.2005.0108.x
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1007/s11606-005-0102-8&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=16050855&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000230290800009&link_type=ISI) 

25. 25.Wilkinson H, Whittington R, Perry L, Eames C. Examining the relationship between burnout and empathy in healthcare professionals: a systematic review. Burn Res. 2017; 6: 18-29. doi:10.1016/j.burn.2017.06.003
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/j.burn.2017.06.003&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 

26. 26.Barraza JA, Zak PJ. Empathy toward strangers triggers oxytocin release and subsequent generosity. Ann N Y Acad Sci. 2009; 1167: 182-189. doi:10.1111/j.1749-6632.2009.04504.x
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1111/j.1749-6632.2009.04504.x&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=19580564&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 
    
    [Web of Science](http://www.annfammed.org/lookup/external-ref?access_num=000268444300019&link_type=ISI) 

27. 27.Tackett S, Wright S, Colbert-Getz J, Shochet R. Associations between learning community engagement and burnout, quality of life, and empathy among medical students. Int J Med Educ. 2018; 9: 316-322. doi:10.5116/ijme.5bef.e834
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.5116/ijme.5bef.e834&link_type=DOI) 

28. 28.Fiske ST. From dehumanization and objectification to rehumanization: neuroimaging studies on the building blocks of empathy. Ann N Y Acad Sci. 2009; 1167: 31-34. doi:10.1111/j.1749-6632.2009.04544.x
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1111/j.1749-6632.2009.04544.x&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=19580549&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 

29. 29.American Academy of Orthopedic Surgeons. Physician empathy a key driver of patient satisfaction: new study supports enhanced physician-patient communication training. ScienceDaily. Published Mar 1, 2016. [www.sciencedaily.com/releases/2016/03/160301114118.htm](http://www.sciencedaily.com/releases/2016/03/160301114118.htm)
    
    

30. 30.Walsh S, O’Neill A, Hannigan A, Harmon D. Patient-rated physician empathy and patient satisfaction during pain clinic consultations. Ir J Med Sci. 2019; 188(4): 1379-1384. doi:10.1007/s11845-019-01999-5
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1007/s11845-019-01999-5&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 

31. 31.Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract. 2013; 63(606): e76-e84. doi:10.3399/bjgp13X660814
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYmpncCI7czo1OiJyZXNpZCI7czoxMDoiNjMvNjA2L2U3NiI7czo0OiJhdG9tIjtzOjIzOiIvYW5uYWxzZm0vMjIvNC8zNTIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

32. 32.Chekhov A. The Greatest Short Stories of Anton Chekhov. Fingerprint Publishing, 2021.
    
    

33. 33.Engelhart K. “Should Patients Be Allowed To Die From Anorexia?” The New York Times Magazine. January 3, 2024. [https://www.nytimes.com/2024/01/03/magazine/palliative-psychiatry.html](https://www.nytimes.com/2024/01/03/magazine/palliative-psychiatry.html)
    
    

34. 34.Burstein DS, Liss DT, Linder JA. Association of primary care physician compensation incentives and quality of care in the United States, 2012-2016. J Gen Intern Med. 2022; 37(2): 359-366. doi:10.1007/s11606-021-06617-8
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1007/s11606-021-06617-8&link_type=DOI) 

35. 35.Beckman TJ. The imposter syndrome in physicians. Mayo Clin Proc. 2022; 97(11): 1964-1965. doi:10.1016/j.mayocp.2022.09.014
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/j.mayocp.2022.09.014&link_type=DOI) 

36. 36.Shanafelt TD, Dyrbye LN, Sinsky C, et al. Imposter phenomenon in US physicians relative to the US working population. Mayo Clin Proc. 2022; 97(11): 1981-1993. doi:10.1016/j.mayocp.2022.06.021
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/j.mayocp.2022.06.021&link_type=DOI) 

37. 37.Palmer C. How to overcome impostor phenomenon. Monit Psychol. 2021; 52(4): 44. [https://www.apa.org/monitor/2021/06/cover-impostor-phenomenon](https://www.apa.org/monitor/2021/06/cover-impostor-phenomenon)
    
    

38. 38.Berwick DM. Era 3 for medicine and health care. JAMA. 2016; 315(13): 1329-1330. doi:10.1001/jama.2016.1509
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1001/jama.2016.1509&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=26940610&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 

39. 39.Trockel M, Sinsky C, West CP, et al. Self-Valuation challenges in the culture and practice of medicine and physician well-being. Mayo Clin Proc. 2021; 96(8): 2123-2132. doi:10.1016/j.mayocp.2020.12.032
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/j.mayocp.2020.12.032&link_type=DOI) 

40. 40.Trockel MT, Hamidi MS, Menon NK, et al. Self-valuation: attending to the most important instrument in the practice of medicine. Mayo Clin Proc. 2019; 94(10): 2022-2031. doi:10.1016/j.mayocp.2019.04.040
    
    [CrossRef](http://www.annfammed.org/lookup/external-ref?access_num=10.1016/j.mayocp.2019.04.040&link_type=DOI) 
    
    [PubMed](http://www.annfammed.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fannalsfm%2F22%2F4%2F352.atom) 

41. 41.Pipas CFCJ, Neumann SA, et al. The Rise of Wellness Initiatives in Health Care: Using National Survey Data to Support Effective Well-Being Champions and Wellness Programs. AAMC; 2021. [https://store.aamc.org/downloadable/download/sample/sample\_id/465/](https://store.aamc.org/downloadable/download/sample/sample_id/465/)