35 Years of Burnout

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.

2 Responses to “35 Years of Burnout”

  1. 1 Faudes March 4, 2016 at 5:16 am

    My father has been a physician for 30 years now and he is very depressed with this current situation. He has decided that in his private practice he will only take certain medical insurance plans, accept with reluctance the fact that some of them have removed him from their provider lists because he does not feel comfortable complying with most of their dehumanizing practices, and even though he is not buoyant in money right now, he, who also decided not to be a hospitalist, (only hospitalize his own pts from his private practice), is more at peace than many of his colleagues who are suffocated and tired and rebelious to the point of this showing in their decline in effective patient treatment. More and more patients have arrived paying cash only. I am entering residency now and I did not understand him until now, and I support his decision and I hope I can be able to do the same. I wish for a change.

  2. 2 meyati March 4, 2016 at 7:37 am

    For me, I think that the patient that doesn’t have normal reactions, e,g, multiple medication allergies, and so forth is a burn out factor. These patients have usually been stressful throughout the ages, and physicians label them in many negative ways, but they exist.

    A physician loses control and with the pressures caused by today’s mandates, protocols, and billing and payments. A physician isn’t free to be a physician. An example is that I was bullied into taking a low dose of statin. After 4 months, I had severe cramps, swollen feet, and I urinated black for a little over 90 days. I seemed to be recovering, when my Achilles tendons went out. The right tendon ruptured. My primary care physician was so miserable and frantic. He had been trained to believe that the side effects were psychsomatic, and CoQ 10 was an expensive placebo.

    I did have foot and hand spasms in his office, and he was kind enough to label them as seizures to give me safety from future medical care. He reached the point of stress and guilt that he found me another physician.

    This medical group puts tremendous pressure on its medical staff to prevent CVAs of any type by prescribing statin for cholesterol/lipid control. MediCare, state run Medicaid, and the NIH all demand a certain percentage of patients to be on statins. I know that my old physician probably advocates for CoQ 10 now, which should help.

    I just wonder what he stress he suffers when he has another patient that is also barely in range, and the patient says-No-. What does he feel? What does he think? because he is ordered to put the patient on statin.

    I knew a USN surgeon that was at Iwo Jima. He wasn’t on a hospital ship, but on a troop transport. The Navy made a 90% error in estimating how much anesthesia was needed for casualties. They obviously greatly under estimated the casualties. By 1100 on day one of the invasion, the surgeons were doing surgery without any anesthesia. What really bothered this surgeon was that fresh troops helped tend to the wounded. They knew that if they were wounded that they would be on the table and under the scalpel without any anesthesia, but they calmly comforted the wounded and climbed off the ships to hit the beach. After Iwo was finished, roughly 2/3rds of these surgeons had nervous break downs, and about a third of them recovered. My doctor never had the breakdown, but he wished that some how he could just loose control. He even prayed that he could lose his mind and forget. He became an OB/GYN, as many other military surgeons did.

    I don’t know the answer to America’s burnout problem, This loss of control also creates helplessness. The eyes of today’s physicians are like the eyes of the WW II combat surgeons, and I’m seeing it more often.

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