Abstract
When I started noticing signs of burnout in myself 7 years into my work as a family physician, I was out of luck. Back then, burnout was not talked about, and most studies addressed only incidence, with a rare article mentioning prevention or interventions. Although I loved medicine, my job was exhausting me in an extreme way, and time off didn’t help. The typical day felt like an obstacle course as I struggled to meet the needs of every patient with empathy amid soul-crushing productivity and time pressures.
Overseas medical missions were a breath of fresh air, with our focus on old-fashioned diagnostic skills, making a difference, immensely grateful patients naive to Dr Google, and that increasingly elusive concept in modern Western medicine: simplicity. Such opportunities to provide exceptional care in humble villages lacking the luxuries of modern life always energize my work back home. They connect me deeply to the vocation that drew me to a life devoted to service when I chose the arduous road to become a physician. Despite all the struggles, a life in medicine has been meaningful because it’s grounded in something sacred: the patient–physician relationship.
Enter the scene the EHR, the ultimate symbol of the WALL that now exists—physically, emotionally, socially, spiritually, medically—between physician and patient, frustrating and alienating one from the other. Modern technology, excessive governmental regulation and interference, self-serving mega-mergers, and insurance company intrusions continue to displace physician and patient from the center of medical care—where they belong and where they both long to return.
In the midst of all this disruption, my soul has longed for mission medicine and the simplicity of pen and paper, make-shift dispensaries, the gratitude of patients who value a physician’s care and hard-earned expertise, and the clinical autonomy we earned through apt education and training. In reality, our autonomy was snatched from us while we were too busy caring for people, neglecting ourselves, and too exhausted to notice.
More than “Burnout”
Burnout is a syndrome that evolves over time as a response to chronic workplace stress. 1 “The 3 key dimensions of this response are an overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment.” 2 All caregiver fields involving interpersonal relations and, in particular, frequent emotionally intense interactions are susceptible to the occupational hazard of burnout. This includes physicians and everyone in health care as well as clergy, teachers, therapists, dentists, veterinarians, attorneys, nonclinical caregivers in the home, and others.
Yet, I believe what many (and perhaps most) physicians are experiencing goes deeper than job-induced burnout, reaching the core of our being and the profound call to serve that drew us to medicine. A physician’s sense of well-being is intimately tied to his or her ability to care for people well—to make the right diagnosis, to show empathy. All my best memories from 25 years in medicine involve other human beings and my ability to improve their lives, ease their suffering, and shine a light of hope in their dark moments. This is what nurtures the soul of the physician, and it cannot be manufactured while spending most of our days staring at a computer screen, clicking away like one more machine.
Over 25 years, I’ve seen the art and science of medicine engulfed by the business of health care. Both “health” and “care” are often lacking from the practice of medicine in settings that, increasingly, place profits over people—including patients and their physicians. We feel the crushing impact of these practices, and it’s eroding our individual and collective servant souls. I agree with the authors of a 2018 article that many physicians are not “burned out.” “They are suffering from moral injury.” 3 It is not the practice of medicine that is burning out physicians but our inability to practice our craft in its purest form—always keeping patients’ needs at the forefront of a relationship based on trust.
For many of us, eventually a day comes when we can no longer endure this sterile work life devoid of meaning. The garden of the soul needs watering, and we cannot give what we don’t have.
Indeed, an invisible wound lies deep in the heart of countless physicians and needs immediate attention. We don’t merely need a vacation, resiliency training, or to become experts in mindfulness—although these measures may help us cope. Self-care and leadership development are critical, but not sufficient, when so many system inefficiencies and obstacles to care persist unaddressed. 4 Some of us need urgent triage and cardiopulmonary resuscitation for the soul, but what we all need most is meaningful support and responsive leaders who did not assume their role as an escape strategy from their own burnout.
We need reliable leaders who understand our real needs by involving us in the process of change and who are committed to both support and equip every employee in their professional roles and as human beings. We need a workplace where we feel valued and are treated with respect. In short, employees must be equipped for their essential work, and the workplace must be humanized.
Many clinicians have sounded the alarm for decades about the rising prevalence of burnout, moral distress, and, more recently, moral injury. The 2019 National Academy of Medicine Consensus Study Report acknowledges clinician burnout as a “major problem across the nation” and provides recommendations for employers to implement. 5 The report affirms the intuitive concept that interventions supporting professional well-being impact one’s ability to provide excellent care. It also stresses the need to address systemic factors, barriers to care, and the organizational culture and environment that contribute to burnout.
How We Got Here
The “Triple Aim” has defined the mission of countless health-care organizations for over a decade: achieving a healthier population in a cost-effective manner while ensuring patients are satisfied with their care. 6 Although this target is specific to health care, the core concepts apply to every field.
Unfortunately, the Triple Aim not only breeds but also magnifies burnout. Several authors have noted, and countless medical professionals have experienced, the significant omission within these goals: where is the one providing care? Who ensures we have all we need, as professionals and as human beings, to care for an increasingly complex population with epidemic rates of depression, anxiety, suicide, obesity, cancer, and chronic illness?
In the 2019 book, Recapturing Joy in Medicine, I call the Triple Aim the Triple Whammy because it creates a no-win situation for those providing care. Studies show medical professionals who pursue these aims while unsupported and burdened by obstacles invariably burn out, which makes achieving these goals impossible. 7 Even worse, burnout can lead to medical errors and more defensive medicine, potentially worsening clinical outcomes and costing more. 8 This is the very opposite of the Triple Aim goals.
This knowledge begs the question: how many work settings place their employees in such a hamster wheel of unachievable goals—to exhaust themselves while getting nowhere—and then blame, shame, or fire them when they fail?
A Way Forward
The 2014 article, “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider” offers steps employers can take to equip and support the medical team as they care for people. 9 The fourth aim—supporting and equipping caregivers with a focus on their experience of providing care—should be the first aim, and it must be prioritized urgently during an ongoing epidemic of physician burnout and suicide. 10 “Clinicians who protect their own health, including mental health, provide better care for others.” 11
Yet, this creates a challenging dilemma for physicians, arguably one of the most regulated and scrutinized professions that exist. Concerns about repercussions on their hard-earned medical licenses and ability to practice medicine if seeking care for themselves—especially mental health care—often keep physicians from seeking help. In these cases, stress and burnout may lead to isolation and, at times, depression and all progress unaided, placing physicians and, potentially, their patients at risk. Thankfully, many states have begun to address this through legislative protections that consider both patient safety and the physician’s well-being. Still, much more must be done, and fast, including educating nonclinical administrators who so often pile on more stress with little understanding or empathy regarding their impact.
The Great Divide
“Many approaches to reversing ‘burnout’ still place the burden on physicians while ignoring the unsupportive, toxic environments at the core of this crisis.” Many still misconstrue burnout as an experience of weak individuals while neglecting to address pervasive system failures and moral predicaments that burden and tear down highly resilient individuals who, like all human beings, have a breaking point.
A 2013 survey of over 1600 physicians revealed a substantial divide between how administrators felt their system supported physicians and physicians’ experience in the workplace. Physicians ranked various elements of engagement they valued, and the top 3 included (1) respect for their skills and competency, (2) sensing their input was valued, and (3) good relationships with their physician colleagues. 12 Next in line was life–work balance and the opportunity to have input as to how their time is spent each day.
The reality of many physicians’ experience in 2020 is miles from these top 5 “engagers.” In particular, the ongoing devaluing of their years of sacrifice and breadth of education and expertise coupled with a demoralizing leadership void and a dangerous loss of autonomy contribute to burnout, disengagement, and the exodus from clinical practice that is placing the very future of medicine at risk. Administrative burdens and superfluous tasks from inadequate EHRs are merely one example of workplace fuelers of burnout. A compelling 2019 article in Health Affairs tied in-basket glut to physician burnout. 13
The need to equip physicians to thrive in an ever-changing and increasingly complex health-care system must be addressed. In fact, “no area has been so ignored in the push for health-care reform as the need to prepare and position physicians to succeed.” 14 Organizations that value physicians invest in their development as leaders to enable them to care for patients well and lead their teams effectively.
Employers must find a way to prioritize the needs of the ones providing care so these goals are achievable without compromising their effectiveness, health, and well-being. With more than 60% to 70% of physicians now employed by someone else, it is crucial for employers to have a proactive plan. The health of our medical workforce depends on it, as does the health of their patients. Thankfully, centers of excellence already exist, though they are still young, and outcomes-based research of long-term impact is needed. These centers include Mayo Clinic’s Office of Support Services and the Stanford program, which promotes improving the work experience, fostering effective teamwork, and prioritizing high-quality care, efficiency, and life–work integration.
Omissions in Need of Action
Three common omissions in the conversation and among strategies to sustain physician wellness deserve more attention and prominence in prevention strategies.
Unexpressed Grief
Medical professionals need time and space to grieve, to process the stressful, frightening, sad, devastating experiences we have on a regular basis. Some medical professionals suffer from job-induced post-traumatic stress disorder that remains undiagnosed and untreated. Beyond the need to involve mental health professionals more proactively, chaplains are underused professionals who can support a clinician’s emotional and spiritual health.
Time Pressures
The average primary care physician has an absurd 7 to 10 minutes of face-to-face time available per patient. Thankfully, the direct primary care model 15 has emerged to remove middlemen and reclaim efficiency, cost savings, and meaning for physician and patient. We need more models like this one that meet the needs of both.
Individual Attention
In our modern world, people are starved for connection. The most effective strategies will involve models in which every employee is known and valued. Some solutions will apply to most employees; others must be individualized through relationship. This alone has the potential to revolutionize the experience of work and increase engagement, productivity, and joy.
Building Community by Fostering Wellness
Initiatives to foster “wellness” in the workplace must be genuine, incorporating and going beyond the basics. These include having healthy options in cafeterias and break rooms; spaces that incorporate silence; areas that facilitate movement, such as on-site gyms, under-desk pedalers, and standing desks; access to coaching and counseling services; and the like. Beyond these basics, the workplace must mitigate stressors and remove obstacles to care such as inefficient EHRs, meaningless regulations, and care-delaying preauthorizations.
Thinking outside the box is essential, as is involving those who will benefit when designing new programs and accessing or developing new resources. At Rosen Medical Clinics, they prioritize employee well-being by ensuring each workstation is ergonomically sound. Some medical schools bring in a certified public accountant to assist their students with time-consuming tasks such as taxes. The workshop is so practical that, by the end, students simply need to mail their completed documents. Thoughtful initiatives like this one can be part of a sincere commitment to remove day-to-day stressors.
People committed to prioritizing healthy practices can help change workplace culture by being intentional. An office-wide fun-run or serving meals together at a homeless shelter can foster emotional, spiritual, and physical wellness; enrich people’s lives; and build a sense of community—a powerful antidote to the sense of isolation so common in burnout.
What Other Professions Can Learn
So how does this relate to burnout in other fields? After publishing the book, Recapturing Joy in Medicine, I have heard from nonclinical professionals who find the content highly relevant to their fields—from attorneys to veterinarians to teachers. It seems all of Western society is falling prey to the same maladies—exalting profits and productivity over people and prioritizing speed over quality.
In every profession, interventions to prevent and reduce burnout in the workplace must begin by placing people first. Those who do burn out must be supported, not blamed, judged, or made to feel inferior. System inefficiencies and bureaucracy must be addressed to remove obstacles that exhaust and frustrate even the most engaged employees. Emotional, spiritual, and mental health needs must be acknowledged, not stigmatized or overlooked as something to be left at home, as if we could compartmentalize our humanity. In fact, what is often lacking is the sense of meaning that comes from human connection.
Championing a Culture of Wellness
When people see themselves as part of a greater whole and become intentional influencers of workplace culture, the ripple effect can be powerful, inspiring, and contagious. For some of us, a new calling can emerge. My experience of burnout launched a new calling to support my colleagues collectively as a speaker and retreat leader and one-on-one as a physician coach. This tremendous honor has been one of the most rewarding experiences of my professional life as well as healing, even redemptive, to my soul. Much of my work now revolves around coaching physicians through burnout to recapture a sense of meaning, purpose, and joy in medicine and in life. I also advocate for our profession and for our patients from the exam room all the way to the Capitol.
A culture of mutual respect with true teamwork that stems from valuing each other’s contributions must be nurtured so a sense of genuine community can grow. Regardless of our vocation or profession, the workplace needs to be humanized. Let’s make our work be all about people…because it is.