One of the most prominent definitions describes burnout “as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with people in some capacity“. (Maslach, Jackson & Leiter, 1996)
In 1974, the year I started medical school back in Sweden, the German-born American psychologist Herbert Freudenberger published a journal article titled “Staff burn-out”. In it, he wrote about the physical and emotional symptoms of burnout, and he described how cognition, judgment and emotions are affected.
In 1980, while I was working in Sweden’s socialized health care system, Freudenberger wrote his book “Burn Out: The High Cost of High Achievement. What it is and how to survive it”.
In 1981, the year I landed on these shores, Christine Maslach published “The measurement of experienced burnout”, with the Maslach Burnout Inventory, which seems to be the standard tool for quantifying this condition, which was first associated with high stress positions in the service sector. It was seen as related to serving the needs of very needy or complex clients with limited resources at one’s disposal.
Early literature on burnout among physicians focused on physicians in pediatric intensive care units, and later on emergency physicians. Today, burnout is discussed in every specialty. It is described as an epidemic that is threatening the continued contribution to our health care system by half of all practicing physicians.
I never heard much about burnout as a resident, young family doctor or even in my early middle age. Now, there is even an ICD-10 diagnostic code for burnout – Z73.0!
The other day, I listened to a podcast by Richard Swenson, MD. He makes the argument that burnout is linked to having too little margin in life. As I listened and tried to imagine which doctors I knew who may have risked burnout from lack of margin, I could only think of a half dozen private practice doctors I knew when I was a resident. The margin theory seems to me to apply mostly to Marcus Welby’s generation of physicians, who did what they loved to do, and although they were in nearly full control of their day, they allowed their professional sense of duty to infringe on their margins, in Swenson’s words, to stretch their physical and perhaps sometimes also their emotional energy to or even beyond their limit.
I believe today’s epidemic of physician burnout is often unrelated to our margins, but in many cases the result of not being in quite the right position or career situation:
I have written before about the “counterintuitive concept of burnout skills” – the “talents” we possess that often draw us into vicious cycles of self-sacrificing heroics to overcome the unfixable limitations of our individual jobs or of the healthcare systems we work within.
In that context, the antidote to burnout is developing and using the talents that bring us the greatest personal satisfaction. When we use those talents, we become energized, and our work becomes fulfilling and rewarding.
In medicine, that switch to what energizes us might be focusing more on mentoring or education, developing a niche of deeper knowledge and greater expertise in an area that we can feel passionate about, or perhaps serving a special needs population of patients, like deaf, immigrant or mentally challenged patients.
But, sadly, burnout in medicine today is increasingly caused by the relentless shift in the demands of physicians’ time, attention and and energy away from serving patients to also, and with no extra time alotted, fulfilling an increasing number of official mandates.
This dichotomy between what we trained for, treating the sick, and what we never imagined doing, inputting data for only remotely patient-centered purposes, is making physicians feel powerless, and that is the driver of today’s epidemic of burnout.
This burnout is different from the other two kinds in that it is unrelated to individual choices or character traits. It is not a “condition” among physicians as much as it is a consequence of the “working conditions” in today’s American health care. It is a direct consequence of what I call the de-professionalization of medicine.
With every passing year, it drives employed physicians in greater and greater numbers toward a desire to quit medicine altogether. Short of becoming self-employed entrepreneurs in their mid- or late career, they see no escape from the shift in emphasis away from patient-focused and to toward data-driven care. All practices, except cash-only ones, must devote increasing resources to collecting data and documenting compliance with mechanistic actions that often seem irrelevant to patients, who all have their own priorities for their fifteen minutes with their doctor.
The solution to, or cure of, physician burnout is obvious and easy, but not on anyone’s political agenda.