Recently I’ve been stumbling across more and more articles about physician burnout. It is a trendy term to use these days and I think a pretty darn good one. It was first used in the field of psychology in 1974 by Herbert Freudenberger, and the meaning has evolved over time. Social psychologists Christina Maslach and Susan Jackson developed the widely used tool for assessing burnout, the Maslach Burnout Inventory which describes burnout as a three-dimensional syndrome composed of exhaustion, cynicism, and inefficacy. It is even in the almighty ICD-10 so it must be the real deal. Burnout described what I went through several years ago very accurately, and I found it to be a good intellectual framework to work from.
Apparently there are people who don’t believe that burnout is ever an appropriate diagnosis. Some declare that burnout is bullshit. “Burnout doesn’t happen” they say. “What you are suffering from is abuse!” At the other extreme, some feel burnt out physicians are all a bunch of pampered millennials crying wolf and that these docs are just suffering from not being tough enough.
“I went through the system and made it through just fine and so should everyone else” they proclaim.
Everyone is opinionated. Any nuance to the discussion is not tolerated and dissent is quickly destroyed by the angry mob, shaming those that disagree into disgraced silence. “Thou shall not be burned out!”
Well, the world is not black and white, and when people make bold absolute statements I am naturally skeptical. I see the world as more of a messy shade of gray. I say both burnout and abuse exist and neither is bullshit.
The problem with this ‘burnout does not exist, it is abuse instead’ narrative is that if there is abuse, there must be an abuser. Maybe it’s a person, the system, the government or some international conspiratorial shadow organization that is also fixing the price of gold and using social media to control us like puppets. It could even be the NFL (I mean, they lied to us about concussions so who knows what other kinds of sneaky things they are up to). But, when we declare that all our problems are from abuse then the only logical way to fix them is to find our abuser, leave our abuser, or change the abuser’s behavior and make them treat us better.
Not only that, but if you follow this line of thinking to its logical conclusion, then any burnout anywhere is abuse. Are all the burnt out teachers, nurses, lawyers, social workers and telemarketers also being abused? All of these professions have a high rate of ‘burnout’. Is it all bullshit? I think we run the risk of watering down the word abuse here. If everyone is abused, no one is.
When I was going through burnout (yes, I am going to unapologetically keep using that term because it is awesome) the last thing I needed was someone telling me I was not going through burnout. It would have been counter-productive. There was no abuser that I could point to, no one magical thing I could fix. It was something much more insidious. It was a combination of all my internal problems made worse by a stressful profession, other complex external events, and the life stage I was in at the time. It was messy. Let’s not kid ourselves; physicians work in a high stress, emotionally exhausting profession. Each and every day I’m working my brain makes thousands of decisions that have real impact on people’s lives, and often have life or death consequences. This weighs on us. It is the primordial soup of burnout.
Taking a step back, I’m not saying for one minute that abuse does not exist in some medical schools, residency programs, and post-training jobs. There are clearly many deranged sociopaths and emotionally broken and abusive people in medicine, and like politicians, they seem to rise to positions of relative power and prestige. Many of these people cannot feel empathy and should clearly not be running medical schools, residencies, and hospitals or training our students and residents. There are countless examples and I don’t want to minimize the horrible emotional and physical abuse many suffer while going through medical training. I’ve seen it up close. There are systemic institutional problems that should be addressed. But I couldn’t find my abuser when I burned out. And there are plenty of good people that care in both medical training and hospital administration. My medical school was awesome and supportive, and despite this a classmate of mine died of suicide in the first two years there. My residency was hard work, but aside from the occasional attending physician acting like an asshole I overall felt pretty supported and listened to. In fact I have mad respect and admiration for the vast majority of people who helped train me and make me the physician I am today. I came out of residency and fellowship optimistic believe it or not.
Five years later I was trying to figure out how to quit medicine and retire.
Exhaustion – check
Cynicism – check
Inefficiency – check
Abuse – Sorry, couldn’t find it. There was no smoking gun, I just burned out.
Not all burnout is caused by abuse.
So why does any of this matter? Why do I even care about this? Why am I wasting one of my beautiful days off typing furiously into a computer when I could be out mountain biking, hiking or sitting on my porch drinking a beer?
Good question. The answer is because it matters. The words we use matters, and when we say “burnout is bullshit” we marginalize the people who are actually burnt out. We are telling many of them to look in the wrong places for the source of their pain and teaching them the wrong solutions to their problems. There is the subtle message that if they cannot find their source of abuse their symptoms don’t exist. If you can’t find the abuse, and burnout is bullshit where does this leave you?
I have seen physicians described as the canary in the coal mine of our medical system, and I love this analogy. For those of you who don’t know, coal miners used canaries in mines because they are very sensitive to carbon monoxide poisoning and will die before the humans when exposed. If the canary stopped singing you knew it was time to get some fresh air. Incidentally, if you were a canary this was a pretty shitty job and your life insurance premiums were probably unaffordable. Anyways, if we want to stop losing canaries we can either:
- Build a better canary; or
- Make the mine less toxic.
When burnout is bullshit and there is only abuse, we are implying there is only one solution: clean up the mine or never step foot in it again. Maybe this is the best long term fix, but this is simply not a practical short term solution for everyone. There are simply not enough good mines for all the canaries to work in yet, and some of the canaries aren’t even functioning well in the mines that are perfectly fine. With burnout there is the implication that both solutions could be helpful. We need stronger canaries to go into those mines and help clean them up. When we convince people that building resilience through mindfulness and gratitude, and optimizing our physical health with exercise and diet is pointless (after all you wouldn’t tell an abuse victim to meditate and be grateful), we do them a disservice. When we tell someone the only way to solve their problem is to find and punish their abuser instead of making themselves the best version of themselves to face the very real stresses of being a physician, we teach them to focus their energy on things that they very likely can’t change in the short term. Sometimes you need to become a more badass canary, and then figure out how to deal with the mine. Again, just to be clear, becoming more resilient is not a good solution to put up with more abuse. Real abuse should never be tolerated. We should continuously shape our work environments to minimize it.
Resiliency is a word that many hate, but I’m going to use it and I’m not going to apologize. You are working in a stressful, high stakes career and you need to be resilient. The thing is though, how you become resilient changes from medical school to residency to the real world. What worked in residency may not work well for private practice. The stressors and sources of pressure change. Now, just to clarify, resiliency does not mean putting up with abuse. ABUSE DOES EXIST AND SHOULD NEVER BE TOLERATED! I think many bristle at the word resiliency because they feel it shifts the burden from the system to the individual, and to be honest many probably use it that way, but resiliency does not assign blame. It does not look for a cause; it is simply a tool for dealing with the world. The truth is we all need to be more resilient because burnout can come from anywhere, and when it comes it is fast, harsh and quite brutal. It often brings friends like depression, substance abuse, and suicide – all one big dysfunctional family. And it can be fatal. Suicide is much higher in physicians than the general population.* Regarding physician suicide, some of these suicides are due to abuse, no doubt; people being pushed to their psychological limits by the very flawed medical training programs and the medical industrial complex, but some of them would have committed suicide if they became an accountant, office manager, or barista. And some of them would die without being abused in any sense of the word.
I want to take a slight tangent here for a moment. There are two kind of people that go into medicine (not really, but go with it for a minute). Some people look at medicine as a calling and could imagine doing nothing else with their lives. They knew from their earliest memories that they were meant to be a healer. It was their destiny. And then there are those that…don’t feel this way. This second group went into medicine because it sounded pretty cool and they didn’t really know what to do with their life, or they wanted to help people and make a difference, or they wanted a stable high paying career, or they were really smart and their parents told them that’s what really smart people do, or they just thought MD looked really prestigious after their name (please don’t become a doctor for this reason). And by the way, it is not socially acceptable for a physician to be in the latter cohort. We all tell ourselves that we went into medicine because it was our calling, even though it wasn’t for some of us. Confusing, maybe even Orwellian, I know.
Well, the real ‘medicine is my calling’ people cannot imagine burning out. It is not in their search pattern. How can you burn out from your calling? The human mind cannot reconcile this craziness. There must be an external reason, hence the need for an external source of abuse, and maybe for some of these people there is. But for others there just isn’t some external, clearly identifiable reason for feeling burned out.
Depression, burnout, abuse, problems with identity and ego; all of these things are real, and all of them have different treatments. They can coexist or present in isolation. It’s comforting to reduce the world to binary black and white categories, but it is also simply wrong. The world is a bit much more complex. Let’s not forget this fact. Let us bring all who suffer into the tent and try and help them.
*Two of my classmates from medical school have died by suicide, and even in retrospect I do not see anything that resembled abuse contributing to their deaths. If we only focus on abuse we will neglect these people and not find the true reasons for their suffering.