We know the origins of the common usage of the term burnout. In the early 1970s the German American psychologist Herbert J. Freudenberger used it to describe work-related stress he saw in physicians. Freudenberger observed that medical practice changed some doctors from passionate idealists to depressive cynics who treated their patients with cold indifference. Investigating further, he found the disillusioned doctors all shared certain traits: a strong work ethic, high achievement, and a tendency to see their work as essential to their identity. Once burned out, they also shared symptoms including disturbed sleep, mood fluctuations, and difficulty concentrating. Long-term stress adversely affected their bodies and minds, keeping them on high alert, as if they continuously faced a lethal threat. Their combination of high work engagement and incessant strain led to a vicious cycle of self-neglect, value revision, changed behavior, challenged relationships, withdrawal, and inner emptiness.
Increasingly, I had found myself easily startled and unable to recall simple words and statistics. I lay awake most nights between two and four in the morning, thoughts racing and heart percussing. I worried about my patients: Would S’s daughter show up? Had I done the right thing for H? Would M fall again? I also ran through long lists of all the things I hadn’t yet done and all the people who were making my life so unpleasant, then conjured up things I might have said or done and, finally, plausible escape routes: a broken hand that precluded typing, the sort of cancer that would get me off work for a good long time but wouldn’t kill me, a family crisis that required my particular presence. I’d drift into an exhausted sleep just before my alarm went off to a new day with a full inbox, a schedule that allowed no time for meaningful note writing, countless other competing tasks and responsibilities, and wholly inadequate time for actually doing those things that could legitimately earn the label patient care or felt meaningful.
What I was seeing was happening everywhere and doctors were beginning to speak and write about it. In Omaha, Byers “Bud” Shaw, a transplant surgeon, stopped practicing when he found himself too anxious to leave his office, much less pick up a scalpel. In Boston, the internist Diane Shannon left medicine because of the constant tension between the sort of medicine she wanted to practice, “compassionate, safe, dependable, connected, and humane,” and a health delivery system that seemed to value and prioritize everything but those elements. An unnamed hospital-based doctor quoted onNPR said, “If I took the time to actually talk with my patients, which is what drew me to medicine in the first place, it meant I fell behind and then spent hours and hours at home in the evening doing the required data entry.” An outpatient-clinic doctor colleague of mine noted different but related pressures in his setting. Even if he finished his notes before heading home, he spent “2–3 hours every day/night on inbox stuff (e-mails and phone calls from patients, nurses, and pharmacists)—this is uncompensated, underappreciated work that we do on a daily basis and bleeds into our evenings and weekends. This work happens whether it is a clinic day or a non-clinic day. There is no escape and no relief.” A doctor’s interests and inclinations push one way, toward patients and care, and the system pushes the other, toward computers and tasks that are essential but not factored into our work schedules.
A 2015 study conducted by the American Medical Association and Mayo Clinic found that over half the doctors in America are experiencing burnout. The rates have increased yearly in recent years, and are far higher than for the general population, even among people with similar education and work hours. They also are, by far, the highest rates recorded among physicians since Freudenberger identified the phenomenon. The study’s authors explain that this epidemic should be of grave concern to all Americans because, in addition to the personal toll on doctors and our rising suicide rates, “burnout appears to impact the quality of care physicians provide, and physician turnover, which [has] profound implications for the quality of the health care delivery system.” That’s bad news for patients, and we are all patients or potential patients. It’s also bad news for American health care, which is seeing more and more doctors reducing their work hours, giving up clinical practice, or taking early retirement at a moment when the Department of Health and Human Services predicts a shortage of forty-five thousand to ninety thousand physicians by 2025.
As a doctor, if one of my patients has a serious, undesirable side effect to a medication or treatment, I change that medication or treatment. I continue it only if there are no alternatives and the patient and I believe the outcome will be worth the attendant agonies. But those in charge of American health care seem unfazed by our current system’s many destructive side effects, including burnout and its harms to patients and clinicians.
Much like our senators and representatives who deprive their constituents of health care coverage while continuing their own extra-special congressional health benefits, they behave as if they believe that people get what they deserve. Words such as resilience and self-care—the trait and skill, respectively, that we are encouraged to developed to combat burnout—suggest the failure is within America’s clinicians, that we have unwisely used up our precious fuel, that we are weak and don’t know how to take care of ourselves. The ubiquity of burnout across specialties and geographic regions suggests our distress is but a symptom alerting the health system to a potentially lethal underlying problem. In the same way a person can have arm pain during a heart attack when a critical artery is blocked, burnout is physician distress signaling that the health care system needs critical care.
Read any of the growing numbers of poignant essays about burnout, and you will find most doctors report what I, too, felt, even at my lowest point: that I still wanted to be a doctor, that the work for me has always been more vocation than job, but that the structures and demands of the health care system had begun preventing me from providing the sorts of care and healing I believed my patients needed, and that was something I couldn’t abide.
From Elderhood by Louise Aronson. Reprinted courtesy of Bloomsbury Publishing. Copyright 2019 Louise Aronson.
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