A Country Doctor Writes:

Physicians today are increasingly viewed and treated as skilled workers instead of professionals. The difference is fundamental, and lies at the root of today’s epidemic of physician burnout.

Historically, there have been three Learned Professions: Law, Medicine and Theology. These were occupations associated with extensive learning, regulation by associations of their peers, and adherence to strong ethical principles, providing objective counsel and service for others.

Learned Professionals have, over many centuries, worked independently in applying their knowledge of Law, Theology or Medicine to the unique situations presented by those who seek their services. They have done this work with a significant freedom that has been balanced by their commitment to the fundamentals of their disciplines and responsibility to their professional corps. They have answered to their clients, their profession and to the legal system of their countries, perhaps with the exception of where the Church has defied or resisted Government.

Skilled workers are different from Learned Professionals in that they, although their work may be highly complex, don’t independently interpret the theories behind what they do, but instead follow strict protocols and orders from supervisors. Examples of skilled workers are nuclear reactor operators, commercial jet pilots and Certified Public Accountants. No matter how much skill we require from nuclear reactor operators, for example, everybody sleeps better at night if they always follow their protocols and we assume that there are protocols for every imaginable scenario.

This is how many people, and particularly those who are now in roles of administration and finance in Government and the healthcare “industry”, have come to view Medicine; they think it is too important a job to trust individual providers to do well in without lots of supervision and protocols even more detailed than those in the nuclear or airline industries.

A few, narrow, specialties in Medicine and probably also in Law and Theology, might lend themselves to closer comparison with running a nuclear plant or flying passenger jets, but the definition of the Learned Professions is that they deal with not only complexity of but also with the uncertainty caused by the infinite human variation in expression of their science.

The narrower areas of Medicine, like joint replacement surgery, have tempted many to compare Medicine with manufacturing, for example. But even joint replacement surgery requires a level of judgement that goes far beyond the manufacturing paradigm, beginning with making the assessment, in collaboration with the patient, whether joint replacement is even indicated and safe for the individual in the first place.

The management of everyday conditions like diabetes, hypertension, depression and abdominal pain requires solid scientific knowledge, yet also involves high degrees of uncertainty and complex decision-making with infinite variables to consider. In other words, to think these conditions can safely be managed by protocols is naive; “guidelines” in Medicine are only broad brush strokes of the general principles we follow or at least consider, but would be detrimental to countless patients if actually followed as if they were protocols.

The argument has been made that Medical Science has grown so exponentially that individual doctors can never stay informed enough to make independent judgments about patient care. Logic dictates that this explosion requires even more independent judgments, because it is simply not possible to develop “protocols” for everything. Anyone can see that a patient with four or five conditions will have issues where what is done for one condition has a negative impact on another, for example. We face this issue in almost every patient encounter.

The other day, I had to prescribe an antibiotic for a patient with a serious blood clotting problem. The antibiotic I thought of using could interfere with my patient’s blood thinner, and the ones that don’t interfere are less effective. There are no protocols for that.

The same day I talked with a student about the risk of serotonin syndrome when you co-administer certain medications. For example, modern antidepressants and common migraine medications could theoretically cause this syndrome. My student had read it in a textbook and our computerized databases warn us every time that prescribing them both may not be a good idea. The literature reports this interaction to be rare enough that major headache societies support using the combination with common sense precautions when both medications are indicated. Making that judgment in individual cases requires knowledge of the drugs, understanding of the patient’s condition, and awareness of the current literature, because textbooks quickly become outdated.

I also talked with my student about the new study that suggests that more aggressive blood pressure targets for treatment of hypertension than the JNC 8 “guideline” are associated with lower rates of cardiovascular events. Which number should one strive for – in a high risk middle aged patient, and in a frail, elderly, patient?

This is why Medicine should still be classified as a Learned Profession. And this is why doctors must hone and honor their scientific knowledge and critical thinking. And this is also why patients, who can get any isolated piece of fact they would ever want from the Internet, still need us as trusted guides, whose understanding of Medicine runs deeper than sound bytes, blog posts, news flashes – and “guidelines”.

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.