Am Fam Physician. 2012 Nov 1;86(9):861-862.
A family physician in her mid-30s was a member of an established group practice. She worked three days per week in the practice and two days per week in an urban clinic for children and adolescents with developmental disorders (e.g., cerebral palsy, mental retardation, Down syndrome). She had been the medical director of this state-funded clinic for four years. Over this time, she increased her knowledge of developmental problems and associated medical conditions, and became attached to many of the families and children who received care in the clinic. The pace in the clinic was difficult at times, but manageable. She valued her work, and felt more satisfied and fulfilled working in the urban clinic than in her group practice. She empathized with the struggles of the youth and their families, and admired the commitment of the clinic staff.
The recession caused severe budget problems for the clinic, however, and cutbacks in a variety of health-related services were mandated. The administration, weighing a host of unpleasant choices, decided to lay off several employees, including a nurse, two social workers, and an administrative worker. The number of patients treated was expected to stay the same; the remaining staff would have to absorb the workload of those leaving.
The physician was devastated when she learned of these decisions. She recognized the great need of these children and families, and had talked with other staff and administration about additional programs she wanted to develop. She now would have to say good-bye to coworkers and abandon her hopes for a larger and more robust program. She realized that the remaining staff, herself included, would have to work harder, and that she would have less time to spend with patients, the part of the work she found most fulfilling. Patients who needed the most help would, in fact, get less help. Our society, she felt, was not utilizing its resources wisely.
Over the next week, she became dejected and sad. She had little energy for her work. When the clinic staff met to discuss the changes, the group seemed to feel as she did: helpless and demoralized. They looked to her for support and guidance, which she did not feel able to provide. What can a physician in this type of situation do, both personally and professionally, to address these feelings?
Demoralization is a state of hopelessness and helplessness that is akin to, but separable from, depression.1,2 It is associated with a sense of subjective incompetence, the belief that a person is unable to express his or her values and achieve his or her goals.3 Demoralization has an existential dimension that is associated with the affected person's experienced losses.1 Many physicians, including family physicians, have strong personal ethics related to benevolence,4 the desire of individuals to act for the welfare of others. This value system comports well with beneficence, the intention of providing aid to those who seek the physician's help, which is the dominant value system in medicine.
In this case, the physician believed in the importance of care for this group of children and their families. She felt that they needed and deserved high-quality, comprehensive care, and that it was her personal and social responsibility to provide that care. She became demoralized when impending staff reductions made her realize that the group would be deprived of what it needed, and she was helpless to prevent that from happening.
Moving past demoralization involves remoralization, or the renewal of one's personal values and the activities that stem from those values.5 This may be difficult if the individual does not or cannot envision a path forward to renewed energy and commitment. However, if not addressed, persistent feelings of demoralization are likely to result in or contribute to burnout.6
There are several approaches to consider in the remoralization process. The physician in this illustration could try to advocate more strongly with clinic administrators for the needs and importance of the clinic, and enhanced (rather than diminished) staffing. She could join stakeholder or advocacy groups that address these same issues on a larger scale. She could promote the needs of developmentally impaired children and families through her own and other professional groups. All of these efforts, if successful, could potentially renew her energies and reinforce her commitment. If they were not successful, however, or if large-scale efforts were not compatible with her personality or interpersonal style, the demoralization and sense of failure could deepen.
Other approaches that are compatible with advocacy efforts on behalf of these children and families involve efforts to address and clarify the physician's own values and how to express them. This may come from her personal reflection or mindfulness of what satisfies her and makes her work feel meaningful.7 It may come from reducing her hours at work and spending more time in pursuits that allow for contemplation and reflection, a recharging that should be accompanied by recognition of what is personally significant. For some, recharging comes from time with family, or from hobbies or outdoor activities. For others, it comes from speaking about personal issues with close friends, colleagues, or counselors.
Demoralization can be painful, but it can also present opportunities for individuals to recognize what is really important to them, and to take action based on that recognition. In this case, the physician may decide to further dedicate herself to the field of her choosing. This may result in additional work at the urban clinic, or at another program that emphasizes the treatment of this population. It may mean participating in advocacy efforts that will result in time away from direct care and a loss of income. All of this may be difficult, but it may also be necessary if the physician is to regain enthusiasm for her professional life.
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1. Clarke DM, Kissane DW. Demoralization: its phenomenology and importance. Aust N Z J Psychiatry. 2002;36(6):733–742....
2. de Figueiredo JM. Depression and demoralization: phenomenologic differences and research perspectives. Compr Psychiatry. 1993;34(5):308–311.
3. Cockram CA, Doros G, de Figueiredo JM. Subjective incompetence as a clinical hallmark of demoralization in cancer patients without mental disorder. Primary Psychiatry. 2010;17(7):54–58.
4. Eliason BC, Guse C, Gottlieb MS. Personal values of family physicians, practice satisfaction, and service to the underserved. Arch Fam Med. 2000;9(3):228–232.
5. Vissers W, Hutschemaekers GJM, Keijers GPJ, van der Veld WM, de Jong CAJ. Development of the remoralization scale. An extension of contemporary psychotherapy outcome measurement. Eur J Psychol Assess. 2010;26(4):293–301.
6. Leiter MP, Maslach C. Areas of worklife: a structured approach to organizational predictors of job burnout. In: Ganster DC, Perrewé PL, eds. Emotional and Physiological Processes and Intervention Strategies. Research in Occupational Stress and Well Being, Volume 3. Amsterdam: Elsevier; 2004:91–134.
7. Epstein RM. Mindful practice. JAMA. 1999;282(9):833–839.
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