Metric Shaming in Medicine and 3 Steps to Overcome It

burnout Feb 02, 2024

Looking back at my career as an emergency physician, I remember how my first year out of residency was a roller coaster ride with many ups and downs practicing as an emergency physician in a semi-rural town in Illinois. But once I found my stride and confidence as an attending physician, I recall distinctly knowing to my core that I was a good doctor. I was strong in my clinical knowledge. I connected well with patients.

In fact, they would often ask if I had a private practice and if I would be their private doctor. I always acted with integrity. I put the best interest of my patients first even if it meant I would leave my shift hours late or the patient might be upset and give me a bad patient survey when they didn’t get a narcotic for pain that could be treated with an anti-inflammatory medicine or an antibiotic for what I knew was a viral illness.

But somewhere down the line between quarterly RVU productivity reports, patient satisfaction scores and door-to-doctor times, all of which are commonly tracked in a community emergency medicine practice, a few years into being an attending, I actually found my confidence recede only to be replaced with a constant need to prove to the world that I am a good doctor. It bothered me that administrators and directors put such heavy emphasis on metrics such as these because after a while, many of my colleagues and I started to feel like our worth was based on these numbers. 

Or perhaps for some, it’s not these metrics but it’s the amount they get paid that they think determines their worth. I heard this from some primary care doctors and emergency physicians who felt as though they weren’t as worthy because they didn’t earn as much as a specialist or a surgeon. At times I had felt this way too as though my worth was determined by my salary or income. 

The problem is thinking that any of these numbers determines our worth, leads us to hustle our way to self-worth. We keep thinking we have to do more, see more patients, produce more RVUs, and get better patient satisfaction scores. We think we have to get the promotion or practice somewhere else where we can earn more. Or we decide we need to specialize and get more training or another degree, and THEN we will feel worthy. 

The problem is THEN never arrives, and we stay on a hamster wheel of unworthiness and shame. Author, speaker and shame researcher Brene Brown says, “Shame is the warm feeling that washes over us that makes us feel small, flawed and never good enough.” 

There was a clear disconnect in my mind because I knew the person I was in the exam room interacting with patients and their families – the consummate, compassionate and connected professional. Yet, when I stepped out of the room, I felt ashamed around my directors that my metrics weren’t better.

I worried I had spent too much time with the patient establishing rapport and getting enough information to make an accurate diagnosis and now my patients per hour number was going to be lower. I made the metrics mean that I was “slow.” And in the fast paced environment of the ER, “slow” was most definitely a dirty word. I also made it mean that I wasn’t “pulling my weight” compared to my colleagues or being a “team player.”

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I made it mean that I wasn’t a good enough doctor in the eyes of my colleagues, director and even the nursing staff who often looked at the list of doctors on staff at the beginning of each day to decide if the day would go well or not with patient flow.

Sure, I was great with patients and provided excellent patient care as I had been trained to in medical school and residency, but the message I was getting now as an attending was that alone wasn’t good enough. I took it to mean I wasn’t good enough. As Brown explains guilt says, “I’m sorry. I made a mistake,” and shame says,”I’m sorry. I am a mistake.” 

Playing the Metrics Game

So I tried to play the game to get my numbers up thinking then I would feel like a good doctor. I hustled to see more patients per hour. I tried to learn how I could generate more RVUs and learned tips and tricks to get those numbers up. To improve patient survey numbers I started to apologize to patients for their wait even though I had little control over how long they waited in the waiting room of our often busy emergency department. 

I started using catch phrases administrators would tell us to use: “Just to keep you [pause] informed [emphasis on “informed” and then pause again], your tests will take about an hour to come back.” As I said the scripted statement, I practically felt compelled to wink during it. I brought them water and warm blankets and snacks if it was appropriate. Meanwhile, I started to feel more like a waitress and less like a doctor.

Ironically, I remember some colleagues remarking that prior experience as a waiter or waitress makes you a “better” emergency doctor. I tried everything I could to get myself out of shame. But, feeling “good enough” by changing those metrics eluded me and as Brown writes, “Shame corrodes the very part of us that believes we are capable of change.”  

All of this felt misguided and inauthentic to me. It felt like the emphasis was on the wrong thing. At some point I decided I wasn’t going to pay attention to it, and that I needed to stick to my true north. Now that did not mean I would never get water or a blanket for a patient again or that I wouldn’t keep them updated and informed, I just decided I wasn’t going to do that to get better patient satisfaction scores.

I also decided I wasn’t going to hustle more and compromise my integrity or patient safety for the sake of increasing RVUs. I knew I always did my best and whether that played out in the metrics or not was not something that was worth investing too much of my time or energy on. Furthermore, all I could do was my best and my best was good enough in my eyes. 

But, real transformation came, and I was truly able to let go of the shame surrounding my metrics when, as a life coach, I learned about self-worth and that my self-worth was inherent and something I was born with. I truly started to own that I was born worthy and that there was nothing I had to do, achieve or accomplish to be worthy. My RVU nor patient per hour scores didn’t determine my worth. Nor do any other numbers in my life – my Step 1 board scores, the number on my paycheck, my age or even the number on the scale when I would weigh myself. Neither my relationship status, my job title, my specialty, my board certification status, the number of research papers I had published, nor my academic faculty rank determined my worth.

There are three key mindset shifts that help end metric shaming. 

First, realize the number is neutral. It is not inherently good or bad. It’s just a statistic or number generated by a computer. Even if you are ranked up against your colleagues, your rank is still a neutral fact and number.

Second, know you are worthy always no matter what the numbers are. No RVU number, Board Score, Rank, or Title changes your worth as a human being or as a physician. You were born 100% worthy and you will always be. This can never be taken away from you. 

Finally, now that you know that you are always 100% worthy decide with intention what you want to believe about yourself as a doctor in general. 

You get to decide what those numbers mean and what you will think about them. This allows you to stay empowered when you know you get to choose what you think about those numbers mean. Be kind and compassionate with yourself as you reflect on those numbers.

I like to think thoughts like: 

I’m a caring doctor who is always doing her best. 

I’m an astute diagnostician and sometimes it takes time to get to the right diagnosis. 

Whenever numbers such as these are shared with me, I remind myself it’s just a number and it doesn’t have to define anything about the type of doctor I am.  

Ultimately what matters most is not some arbitrary metric, but what I think about myself . And I already know that I’m a doctor who always practices with integrity and is always doing her best. 

As you intentionally decide what you make those metrics mean about you or your colleagues I encourage you to choose kindness and compassion and know that most everyone is doing the best they can with the resources they’ve been given. 

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Archana Shrestha MD is an emergency physician, mom, wife and life and weight coach. She is the founder of the Mama Docs School where she coaches women in healthcare on ending burnout and also on how to achieve lasting weight loss. 

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