I have some strategies for preventing “physician burnout.” I am a little over 70 years old and am not experiencing any of the symptoms of “physician burnout.” I do not state this out of any sense of pride, but I have tried to be introspective about this so as to offer some advice as to how to avoid this problem.
My approach is fourfold. I shall begin by reviewing the definition of burnout, and, in particular, physician burnout. Much has been written about this recently, but in order to address the individual issues, it is important that we are using the same definitions. Secondly, I shall review some facts about the reality of American medicine. Third, I shall articulate a paradox between what seems to be an epidemic of physician burnout in the context of the reality of American medicine. Finally, I will offer a nine point set of suggestions, which are meant to help to avoid the symptoms and signs of this syndrome.
Job burnout is not a new idea, and it is not specific to medicine. It has been in the psychology/psychiatry literature for quite a long time. It may be defined as a feeling of emotional exhaustion characterized by cynicism, depersonalization and perceived ineffectiveness.
In recent years, many have argued that “burnout” is extremely prevalent; not only in society as a whole but in particular in medicine. It has been said that 50% of physicians have at least one of the three cardinal features: exhaustion, depersonalization and inefficacy. The problem with these kinds of data is that are no adequate controls. It is probably quite common for many people, at some point or another, to experience one or more of these cardinal features. The real question is whether this is more than in a control population and whether they are persistent, rather than transient, symptoms. That information is not available. For these reasons, it is likely that the problem of “burnout” is being exaggerated. Nonetheless the problem undoubtedly does exist in an unknown proportion of physicians.
What are the alleged causes of “burnout?” There are many, of course, but there are five major categories. The first is what is termed “overwhelming demands and work overload” often associated with sleep deprivation and a need to be “superhuman,” by which is meant the intolerance of any errors and the enormous fear that errors will cause harm to patients and /or risk of malpractice litigation. Some physicians believe this is a “zero tolerance game”.
The second alleged cause of “burnout” is what many call social conflicts, conflicting values and a breakdown of the community. In this category falls the so-called work-life balance. That is, what proportion of one’s life can one spend in work, including thinking about work, versus other endeavors, such as family, athletics, artistic pursuits, hobbies, vacation, reading and others. The third of the causes of “burnout” is the lack, or perceived lack, or loss of various resources. In the context of medicine, this might be inadequate information systems, physicians’ assistants, nurses, secretarial help and scheduling systems. The fourth cause is insufficient rewards. These can be divided into two categories: monetary and nonmonetary rewards. In the latter category might be a sense of feeling respected and of doing something that is meaningful. The last of the five major causes of “burnout” is what many have termed “lack of fairness.” This issue of fairness affects not just medicine, but is pervasive all over the world in many different contexts. In fact, it is really a zeitgeist, or a spirit of the times. Many groups, defined by multiple criteria, feel marginalized. This could be a religious group, a racial group, a gender orientation, and so on. One can easily recognize this phenomenon by simply reading the lay press, which reflects the fact that this issue is very important in the world at large. It has led to an enormous amount of angst, and beyond just angst, actual conflict and even war. This feeling of marginalization and not being treated fairly is widespread in society, so it is not surprising that it could affect doctors as well. In summary, the five major causes of “burnout” are: overwhelming demands, social conflicts, lack or loss of resources, insufficient rewards, and absence of fairness.
It is important, in this context, to consider the issue of suicide. It has been argued by some that there is a serious increase in suicide among physicians and that this suicide rate is related to the underlying phenomenon of “burnout.” In fact, it has been argued that for women physicians there is a 130% higher rate of suicide than in the general population with a relative risk of 2.27; and in male physicians, a 40% higher rate of suicide than in the general population for a relative risk of 1.41. These data, however, are highly suspect. In the first place, all data about suicide are questionable, as suicide is often not reported for what it is. It is always very difficult to know how much suicidality there is. And if there is a problem of an increased suicide, most authorities would agree that this increase is mainly seen in middle-aged nonprofessional males; not in physicians. Another problem with these data is the reported cause of death. Different subgroups in society are more successful at hiding suicide, which is still considered to be shameful cause of death and is often hidden by families. It is possible that suicide is more often reported in physicians than in other groups in society, a phenomenon that will produce an artifactually elevated suicide rate in physicians compared to society at large. Even if the suicide rate were higher in physicians, there is no convincing evidence that suicide is directly connected to “burnout.” It is more likely that reverse causality is at play, by which I mean that traits that lead to people becoming physicians may run together with depression, which is clearly related to suicide risk, and physicians have easier access to the methods of suicide (e.g. drugs), such that an equal amount of depression might lead to more suicide in physicians than in non-physicians.
Why do people go into medicine? Many people, in retrospect, like to argue that they pursued medicine because of an innate and deep desire to help others. In actual fact, however, it is more likely that people pursue medicine because they can. It is likely that people pursue medicine because it is a prestigious, high-paying and secure profession. Let us review the actual statistics about prestige, pay and security of medicine in the United States.
Let us start with prestige. Several Harris polls on this subject can be utilized. The most recent, which roughly reflects the results of many earlier polls, lists the top ten most prestigious fields in the United States, based on polls of the general population meant to reflect a representative sample of the American public. In reverse order, these are: tenth: teacher; ninth: architect; eighths: clergyman; seventh: police officer; sixth: engineer; fifth: nurse; fourth: scientist; third: firefighter; two: military personnel; and first: doctor. Put another way, Harris found that 80% of Americans agree that being a doctor is the most prestigious and most trustworthy job in America. So, it is undeniable that medicine is very prestigious, and many people for this reason, understandably, want to pursue medicine, if they are capable of doing so.
What about pay for doctors? For these data one may consult the Occupational Outlook Handbook, published by the U.S. Bureau of Labor Statistics. The last such survey is the one for 2014, but the results have been roughly the same for as long as these statistics have been gathered. These data are reported as median salaries, which is the better method for analyzing this issue as it means that half of all those in a given profession earn as much or more than the median. Average salaries may be misleading as they may be unduly affected by a few at the extremes. In any case, let’s review the top 20 most well-paying jobs and professions in the United States. The top group is a cluster of seven jobs with a median income of greater than $187,200 annually, which is well into the 99th percentile of American jobs and professions. All seven of these are medical jobs. Number one is physicians and surgeons as a group; number two is anesthesiologists, three is orthodontists, four is internists, five is obstetrician/gynecologists, six is oral and maxillofacial surgeons, and the last in the top tier is general surgeons. The next group, right below at a median income of $180,880 a year, are psychiatrists, followed by family doctors are at $180,180. Only then does a nonmedical profession appear. These are chief executives at $173,320 (remember these are median salaries; mean salaries for CEOs would be higher, distorted by the relatively small group with very high compensation). Near the bottom this list of the 20 top jobs are other professions. Architectural and engineering managers are at $130,620 annually. Petroleum engineers: $130,050; computer and information systems managers: $127,640; marketing managers: $127, 130; air traffic controllers: $122, 340. Finally, number 20 on this list is pharmacists at $120,950. All of these are well into the 99th percentile of all jobs. Of these 20, 14 are physicians and dentists. In summary medicine is overall the highest-paying field in the United States by far.
Finally, a brief word about job security is in order. In the United States, the unemployment rate for physicians is virtually zero. Any able physician who wishes to work can do so. So in summary, medicine in the United States is prestigious, high paying and secure; more so in all categories than any other job or profession
Do people go into medicine because of their innate desire to help people? Although many clearly pursue medicine for this professed reason, the truth is that medical students are people who have entered medical school in enormous competition with others because they have the ability to succeed at tests and obtain high grades. In order to be admitted to medical school in 2015, one had to have had a grade point average of at least 3.7 and Medical College Admission Test (MCAT) score of at least 30, both well over the 90th percentile of all undergraduate college students. These are the minimum standards, independent of any affirmative action programs that are aimed at diversifying the medical school pool. The average grade point averages and MCAT scores are considerably higher and depend to some extent on the competitiveness of the specific medical school. This means that people going into medicine are not doing so entirely because they want to help people. There are numerous jobs and professions that involving helping people, including teaching, social work and many others. They are probably pursuing medicine because they can. Any why? At least in part this is because medicine is a profession that is prestigious, high paying, and secure. Candidates applying for medical school are judged almost entirely on their capacity to take tests. There is no requirement for entering medical school that requires a well-developed theory of mind, by which is meant empathy. Medical schools allege that they consider interpersonal talents, but these are hard to assess and, in reality, are only used to select within a population of candidates who, at a minimum, have obtained high grades and high standardized test scores. Besides, empathy is hard, or impossible, to measure, and probably does not correlate well with performance in medical school, which, after all, is still measured by the ability to memorize facts and perform well on tests.
With this prologue in mind, we are faced with an obvious paradox. Why is there so much emphasis, and so much talk and angst about burnout in a time and in a place where the causes of burnout are actually the lowest in the world and the lowest in history? Why are doctors “burning out” when they are in the profession that many other people would have liked to pursue; when they are held in high regard by society; when they are paid the most money and given the most job security? What makes them so unhappy? The answer can be summarized in a single word: entitlement. The people who have become doctors feel entitled, not only to the highest pay, the most security and most respect, which they have, but they also have the unrealistic expectation that they can also succeed and are, indeed, entitled to succeed at whatever other aspect of life they wish to pursue. This includes family life, athletics, music, literature and art. These are people who have been used to getting all As and obtaining the highest scores on tests, so they expect a life with essentially everything. When this is not realized, they become quite frustrated and that frustration leads to the symptoms of burnout. The romanticized caricature of the doctor in the popular media as the beautiful/handsome, brilliant polymath has fueled this unrealistic expectation.
So, what are the antidotes for physician (professional)“burnout?” In order to develop antidotes for “burnout,” it is worthwhile to consider what it means to be a professional. Justice Louis Brandeis articulated some very eloquent thoughts about this which have acted as the basis for the Contract on Professionalism that was created by the American College of Physicians/American Society of Internal Medicine and the European Federation of Internal Medicine. Brandeis’s main point was that the central feature of a profession is the characteristic of altruism, by which one means the consideration of the feelings and the well-being of others over those of oneself. Professions are also characterized as possessing a specialized body of knowledge and self-regulating. In a profession, success is measured by more than just monetary reward or external prestige. Rather it is measured by the ability to help others. A profession provides a service that is in the public’s welfare. In return for that service, society is prepared to provide physicians an extraordinary amount of respect, security and money. And furthermore, members of society are willing to share with physicians the most intimate and personal details of their own lives, because they have confidence that the physician cares about them and not necessarily about his or herself. This is the social contract between society and doctors. The major antidote for “burnout” is to be a professional.
I shall outline a nine point strategy for avoiding “burnout”. First, try working in a truly resource-limited environment. When you pursue this it is very important to avoid any condescension when visiting these other environments where people are working with many fewer resources. Rather, try to learn from the people who are functioning in these environments how they are often times able to it so effectively. I interview neurology resident applicants annually and have been doing this for about 30 years. Over the past several years there has been a dramatic increase in the number of medical students who come to us saying that they are interested in “global” medicine. I think much of this was stimulated by the work of Paul Farmer, one of my colleagues at the Brigham and Women’s Hospital in Boston. The book by Tracy Kidder, “Mountains Beyond Mountains,” written about Paul farmer and his work has been widely read by developing doctors. This has had an enormous impact on young people going into medicine, and many of them tell us that they are interested in “global” medicine. However, when I ask them what they mean by global medicine they often respond that they would like to travel to some developing part of the world and try to help people in that environment. On the face of it, this sounds like an altruistic goal, and to be consistent with the phenomenon of professionalism. But, in actual fact, it often is seen as condescending, self- aggrandizing and even counterproductive. To appear for a brief time in another person’s environment trying to bring them what one considers is a “superior” form of medicine is in fact a very narcissistic view of the world. Rather, what we would hope is to learn something about how it is that people often function so effectively in these challenging environments. This kind of work in truly resource-limited environments does not require traveling across the world. One can accomplish this in one’s own city or town very easily. In our own program, we have a neurology clinic in the Healthcare for the Homeless program here in Boston where we provide neurological consultations. It is possible to practice medicine very effectively in a resource-limited environment. Learning this lesson helps one feel much less sorry for oneself when dealing with some of the creature comforts, the absence of which cause some of the frustrations that lead to the phenomenon of “burnout.”
Number two in my nine point program is to try to empathize with the patients, but do not expect them to empathize with you. This is difficult for doctors, because as I articulated above, they were accepted into medical school because of their superior ability to do well on tests; not because of their ability to empathize. It is, however, possible to consciously learn to empathize more effectively. Do not expect the patients to return this courtesy. Remember, this is an altruistic profession. I remember being told when I was growing up in medicine that, if Adolph Hitler were to be brought into our emergency department with an illness or injury, it would my duty to do everything in my power to treat him as effectively as possible. His political and social views have absolutely nothing at all to do with our practice of medicine. This is, of course, purposely, an extreme example, but it is quite remarkable how many young doctors are actually offended by the fact that their patients do not necessarily share their own views. Patients may be quite different than oneself, politically and socially, but that has no bearing on being a professional. If one becomes offended by the manner in which patients treat us, it is a certain road to feeling burned out and unappreciated. It is, of course, satisfying when a patient does appreciate our work, but the fact they do not appreciate it, or even curse us, should have no effect at all on our view of our role as doctors.
Number three in my nine point program is to spend less energy on mindfulness and other inwardly-facing strategies and more on recognizing the plight of others, including, of course, other doctors. There is a great deal of emphasis now about spending time on oneself and becoming more “resilient.” All of this is fine, but the reality is our profession should be altruistic; not inwardly focused. The more one thinks about the patient’s difficulties and the patient’s plight, the happier one is with one’s own situation. Taking care of oneself is good practice, but narcissism is a fatal flaw for doctors. If there is one function of the interview process in screening applicants for medical school or residency, it is to weed out the malignant narcissists. Unfortunately, this is hard to accomplish as personality disorders are the most difficult of the various psychopathologies to detect in a brief interaction. The long term record of an applicant is probably better than interviews and test scores at revealing signs of this serious problem, but obtaining these types of data is time consuming and subject to bias. Malignant narcissists are never happy, as their need for accolades cannot be satiated; a circumstance that inevitably leads to disappointment and “burnout.” If “burnout” is, indeed, increasing, it is probably mainly because we are enriching medical school classes with people who are susceptible to it; namely they are too self-centered and lack an adequate theory of mind. The apparent tension between work and life is an illusion. With regard to medicine, work is part of life and life is part of work. I enjoy and play (badly) music. I jog with my wife and our two dogs. I have two children and one has two children (my granddaughters). My wife is a medical publisher and we share both work and life with each other. All of these endeavors help me in medicine and medicine helps me in these endeavors. Trying too hard to carve out time for “life”, as opposed to “work”, leads to frustration and the symptoms of “burnout.”
Number four on my nine point program is to work on a sense of humor and an appreciation of irony. This is not cynicism or depersonalization. Irony is all around us. If one can appreciate irony and see the humor in some of the events that are occurring around one, the symptoms of depersonalization and exhaustion will become much less severe. I refer to an essay that I wrote entitled “The Survival Guide for Academic Medicine.”
In it I describe the academic promotion process and listening to some of the business people who lead our hospital system talk in their special language. It is easy to become saddened by these events, but there is humor and irony in this and this humor and irony can help one psychologically considerably when dealing with day to day frustrations. I quote from my essay on The Health Care Blog.
“Business models now dominate the hospitals. Some of these hospital leaders are trained as doctors, but they have been transformed into something very different. Recall the William Cameron Menzies film, “Invaders From Mars,” where beings from outer space come to earth but have no bodies in which to live, so they kidnap people and replace their brains with computers that are controlled by a small antenna that one can find by carefully inspecting at the nape of the neck. Gradually more and more people are turned into these evil automatons. One can never tell when the person next to you is “one of them” without looking carefully for that telltale electrode at the back of the neck. There are many signs that these invaders from Mars have actually taken control of organized medicine. To entertain myself, when I am sitting in some of my seemingly endless meetings, which could be a source of burnout, I occupy myself by simply writing down these words and phrases every time I hear them, and then gradually intercalate them into a paragraph. I then share this paragraph with colleagues, and over the years the paragraph has become elaborated into an entire recitation of what one hears in these meetings. These meetings can ordinarily be aggravating, but this little bit of self-entertainment is quite helpful. Here is my paragraph as it stands right now. See if you recognize any of it. It is called, “Report of the Retreat on Meaningful Use.”
“I’m afraid that if we don’t drill down on our brand equity on the front end, we’ll have to model it out on the back end to align our seamless incentives or pad our ask regarding the co-branding deliverables on the horizon. As an FYI, this empowerment is going to require an elbow-to-elbow champion getting under the covers for a 360 of the e-room to facilitate a paradigm shift in order to achieve buy-in among the stakeholders if we’re going to tip our tow into that water and get the low-hanging fruit before our clients incentivize the burning platform with new metrics. After all, you are the process owner who needs to reach out to the proper bandwidth to push back on the KOLs, or we’ll have to sunset your blue-ribbon committee for not trimming the fat on the real-time escalation project. We need to do more due diligence before we hitch our wagon to that extended outcome measure. And let’s be careful how we roll the message out to our core constituency. We model that projected gap, but we don’t want to get out ahead of our audience before sensitizing them to the moving target. Let’s not drop the meat in the dirt, but rather get a pause point, collapse it up to a high-level statement, and assess the current state in order to connect the dots to achieve the ideal state and have you weigh in at the portal for service-oriented architecture. After all, at the end of the day, we’ll have more skin in the game and be in a better space, if you walk the stakeholders through it so that they can leverage their halo to birddog that from ten thousand feet. If you could create a placeholder to move the needle in the continuous quality improvement initiative, some heavy lifting might give us a report card so that there can be an accountability for a decent ROI. Unless the co-branding produces such a chokepoint so severe that the balanced scorecard causes a culture change, one by each. Just between you and I, you need to parking-lot that issue, take the deep dive, and put the rubber to the road with a degree of commonalty that will re-engineer a sea change in our SWAT analysis, so that we bake it into the budget of the high-level implementation group. We have to move the ball down the field and prevent leakage. Net-net, there is a value added for a win-win rather than a zero sum game. You can manage the matrix organization on the front line and in the back office. With central discipline and local control, we can achieve savings in margin while penetrating that segment of the market. A lot of what we have to do is to reduce our trend is blocking and tackling in different spaces. Bottom line on top, if I don’t report to myself, we could really take a haircut before we can trim the fat out of the box and shift the culture beyond the pilot demonstration program. That having been said, the SWOT analysis shows that if you step up to the plate and evangelize the brand, we can be about the business of creating a palace holder of new buckets with more vertical silos, so that we can finally tell whether we are on foot or on horseback. Comparing apples to apples, it’s clear that this is not a plug-n-play culture, so you’ll have to hold your nose and jump in in order to filter the noise and incentivize the process owners in a more granular fashion before it becomes a major mission drag. A breadcrumb has been forming, so let’s put some stakes in the ground to leverage our insights as enablers of change to circle back on a more granular view, and tee up our clinical levers to mine insights from the benchmarks and beat the waste out of this process. We will cleanse our application platform and get ready for the first wave of ambulatory e-care go-live across the family, and take advantage of the elbow-to-elbow support of the super-users, and be back to 100 percent productivity by the second week. Having said that, we traffic-lighted that report so you can optimize the outcome metrics. If we can get the whole group on board in this arena, we can try to boil the ocean with a six-sigma culture change. We mean to hit this one out of the park and get some substantive returns in the coin of our realm to avoid any mission creep. It’s a nonstarter to analyze the dashboard for cross-walking noise, so we need to slice-and-dice our organic growth, peel the onion, and hardwire the initiative with boots on the ground. If this could be the pause point for a new value initiative, that’s where the metal meets the road. Let’s reach out using our optimized toolkit to go anything north of zero and put a hard stop in this turnkey operation. If you’d like to get some trend lines and traction from this piece, I can ping you a copy of my deck.”
If you hear any of these terms coming from the mouth of somebody who looks superficially to be a doctor, I would recommend that you go behind them surreptitiously and look at the nape of their neck to see if you see that telltale antenna. I’m sure all of you have heard a great deal of that type of language and sitting those meetings can be very frustrating. It can actually lead to discouragement and “burnout.” But, you can see the humor and the irony that is deeply embedded in this change in our culture. Seeing that humor is very helpful in dealing with the frustration that one might have to endure when sitting in these kinds of meetings.
Number five on my list of nine strategies to avoid “burnout” is to collect one’s mistakes, study and share them. Rather than fearing error and thinking that one needs to be a “superman” I encourage all doctors to collect and analyze continuously their own errors. Furthermore, you should share them with your close colleagues. No one has to act like a “superman.” Some years ago, one of my longstanding friends and colleagues told me that he was beginning to collect his own errors, so I began to do the same. I would suggest that you place an icon on your desktop called My Mistakes, and wherever you recognize that you made a mistake, you should take a summary of that case and drop it into that file, with as much data as you can, including a clinical precis of the case, whatever imaging and laboratory tests are available and the ultimate correct answer, if there is one. After collecting a group of these error cases, it is useful to submit them to a person who is expert in cognitive psychology to help categorize them by cause. Error is unavoidable. It is completely impossible to work in a complex environment, in particular a professional environment, such as medicine, without making errors, and these errors occur virtually all the time.
Many are aware of a concept known as memetics. This was a concept popularized by Richard Dawkins. It is simply the social science version of genetics. A gene is a piece of DNA whose express purpose is to replicate itself as perfectly as possible. The most successful genes are the ones that replicate themselves most perfectly. This is articulated in Richard Dawkins’s book The Selfish Gene. The gene has no more lofty social values. It simply wants to copy itself. This can be done with high fidelity, but not perfectly. There are errors. These errors are known as mutations. Without mutation, there would be no possibility for selection and improvement as the environment around changes. The entire basis of genetic natural selection is the existence of these errors; these mutations. Mutations are occurring all the time. Most of them, by simple chance, are not effective and do not improve the gene’s opportunity to reproduce itself accurately. They consequently disappear and are lost in the fog of history. But every once in a while: perhaps once in a thousand, or once in a million, or once in a hundred million mutations, one occurs that happens, by chance, to be effective in dealing with a new environment. Because of this it will improve the gene’s chance of reproducing itself and it will last, at least for a while, until the environment changes again. This is the basis of all natural selection.
The meme is the social scientist’s analogue of the gene. Rather than a piece of DNA, the meme is an idea; an idea that reproduces itself. Dawkins uses the example of women’s right to vote, which was an idea (a meme) that gradually spread across the world, ultimately becoming a zeitgeist or a spirit of the times. Because of the information technology at the time this was happening, the process was slow; taking about 100 years; still very fast compared to genetic evolution. That is the zeitgeist of women’s right to vote cannot be explained based on genetic evolution, but rather by memetic evolution. Ideas (memes) can be clustered to form memeplexes, examples of which would include religions and national ideologies. In the modern world the process of spread of memes is much faster. Electronic communication can allow the spread of a successful meme in microseconds across the entire world. Analogous to mutations, new memes are usually not very successful. They don’t reproduce themselves and are consequently lost. However, once in a thousand, or once in a million, or once in a hundred million these ideas are effective in a new and changed environment, thereby becoming a zeitgeist. These rare events are not necessarily good things. Some of them are bad or frightening ideas, like a new viral disease, such as Zika. One can see the memes about Zika rapidly spreading from brain to brain, carried by electronic media. Good ideas can also spread. The meme, like the gene, has no highly moral or ethical standards. Its success is only measured by how successful it is at copying itself.
This means that mistakes are absolutely critical for progress in medicine, as medicine is based on ideas. As an example, I was trained by the eminent neurologist, Raymond Adams. Consciously and unconsciously I tried to copy Adams. Adams had a mentor, who had a mentor, who had a mentor, etc. I have traced that genealogy back to John Hughlings Jackson, an eminent neurologist in London in the 19th century. If there were no changes in the memes over these several generations, I would be an exact copy of Jackson. Fortunately, no matter how hard we try to copy our mentors, errors are made. Most of these errors were not useful but a few made the mentee more successful in the new environment. Though I will never be the neurologist that Hughlings Jackson was, there is little doubt that I am better adapted at recognizing the neurological complications of HIV, as there was no HIV when he was practicing. I, on the other hand, am undoubtedly much less facile than Hughlings Jackson must have been at recognizing the neurological aspects of syphilis. Though it is not gone, syphilis was much more common in 19th century England than it is today. My students will involve in the same way, as will their students, etc. There is a never ending chain of ideas (memes) that connect our medical ancestors to us and we are a link in that chain which leads to our descendants.
I summarized this in an essay that is entitled “The Value of Mistakes,” published on The Health Care Blog. We are, of course, not trying to make mistakes. We do not try to take out the wrong kidney or operate on the wrong side of the brain. We do the best we can. But our field is very complex. This is one of the beauties of our field. As a result, there will be errors, most of which will not hurt anyone, nor will they likely be helpful. Once in a while the errors may lead to a new insight or a new treatment or sadly a bad outcome. This process is involuntary and is always happening. When in the midst of a change, we cannot see it. One can only appreciate these after a long time has passed, probably decades at the least.
The sixth of my nine point anti-burnout strategy is to study history. Studying history helps in so many ways, but the most important in this context is that it allows one to realize that you are not as special as you have been led to believe. I cannot tell you how many time I have attended lectures and been told by the speaker that “we are now on the threshold” of the cure for all the important medical and neurological diseases – neurodegeneration, inflammation, cancer, and the like – because of our marvelous tools of molecular biology, genetics and imaging. But, in actual fact, this is an illusion. Think back to when Von Leuwenhoek first gazed down his microscope and saw bacteria. Did he not also think he was on the cutting edge, and that his new discovery would, in fact, be the secret to all of medicine? In fact he probably did believe this. In my own professional lifetime, I remember very distinctly this happening regarding the electron microscope. The electron microscope allowed us to see things that we could never have seen before, and many people believed that it would lead to the cure for cancer, just exactly analogous to what Von Leuwenhoek thought so long before. We are always “at the cutting edge.” Our current “cutting edge” is no sharper than it was in eons past. When you think about what our medical ancestors have done, often right in the location where you are working, it is incredibly energizing and helps you fight off the symptoms of what has been called burnout.
Here are a couple of specific examples. Before going into neurology, I trained in internal medicine at Boston City Hospital, a giant hospital in the center of Boston with a very distinguished history of training academic physicians and caring for the poor. In many ways, it was a very difficult place in which to function. I was often overworked and had less sleep than I had wanted. I was taking care of people who often not only did not thank me but would curse me for things that I had to do to them. When I was feeling particularly frustrated and sorry for myself, I would walk out into the courtyard in the center of the old hospital and sit for just a moment and think back about some of the events that had happened there. One event that often came to mind was the Coconut Grove fire, which occurred in 1942, three years before my birth. It was an enormous tragedy; the burning of a very popular nightclub in downtown Boston. Four hundred and ninety-two people were burned to death in that fire, and many others were badly injured. Most of those patients were taken to Boston City Hospital, where the doctors there heroically tried to save as many lives as possible, unfortunately not successfully in 492 of them. It was one of the worst fire disasters in the history of the United States and remains so. But out of that fire came new ideas about taking care of burns, about electrolyte balance; ideas that the doctors were able to parlay into something positive. There were new memes, new ideas, that spread across the world. On one of those nights during my internship, when I had had 10 or 12 admissions and everything was going badly, I cannot tell you how much inspiration this memory would offer me; how much energy it would infuse into me to realize what had happened in this very spot so many years before; three years before I was even born.
At the Brigham, where I currently work, there have been many moments of this kind, but there is one that I will relate because I remember it every time I take our new neurology resident applicants on a tour around the hospital. It was an event that happened in the 1920s. At that time there was a cancer hospital known as the Huntington Hospital right next to the Peter Bent Brigham Hospital and the Harvard Medical School. In that hospital were cancer patients, and among them were people with leukemia. Among them were patients with pernicious anemia, a disease that was characterized by the inability to make new red blood cells. These patients could not make reticulocytes, the red cell precursors. Their hematocrit would drop and they would inevitably die of the horrible disease known as Addisonian, Biermer’s or pernicious anemia.
George Minot and William Murphy were two physicians who heard that George Whipple, at the University of Rochester, had succeeded in inducing dogs to make reticulocytes. These dogs had been phlebotomized to an anemic state and then fed liver. Minot and Murphy heard about this and decided to try this in human beings with pernicious anemia. So, without an IRB, without any red tape, they walked, and sometimes wheeled, very ill patients from the Huntington Hospital across a courtyard in front of the Harvard Medical School to the Peter Bent Brigham Hospital, where they fed them liver. There is a remarkable old move that you can see by going to the journal Blood on the internet and searching under my name and pernicious anemia. The movie was made by Murphy to show at the Nobel ceremonies when they were awarded the 1934 Prize for this remarkable discovery. In the old silent film, one can easily see two patients brought into the Brigham with subacute combined degeneration of the nervous system, the neurological manifestation of pernicious anemia. One can see them eating the liver, subsequently making reticulocytes and a month later walking out the front of the Brigham, essentially cured.
News spread that the cure for pernicious anemia was available at the Peter Bent Brigham Hospital. A very poetic piece was written by Paul de Kruif in his book Men Against Death. “Now sick people came to the Peter Bent Brigham Hospital in extremis, absolutely at the end of their tether. They came with their blood ten times thinner than it should be. They came in with next to no blood at all. Now Minot and Murphy sat by their beds. They poured fresh liver down them through stomach tubes. They kept pouring it down them that way for two, three, four, five days. They didn’t give up though this fellow’s breathing was so faint you could hardly detect it. They stayed by those bedsides feeding liver and liver and more liver and saw life come back into those lost ones whose eyes opened, whose lips began moving, at last, to whisper that they felt a little better. In a week they were sitting up clamoring for something to eat. In less than two weeks they were wanting to walk.”
When you are feeling tired and overworked and underappreciated, remember that Minot and Murphy sat by their patients’ beds administering the “liver cure” often initially via nasogastric tubes as the patients were too ill to take the treatment by mouth on their own. It was, arguably, the most spectacular example of what we now call translational medicine. When I have a bad day, which I do of course, I often walk out into that courtyard and I think about Minot and Murphy heroically curing this lethal disease; sitting by the patients’ beds, certainly exhausted themselves, in order to help others. This memory is inspirational and energizing. Study history. You are not that special. People have been there before you.
Number seven in my nine part strategy for avoiding burnout is to be happy that you are lucky enough to be a doctor. It is the best way that one can spend one’s life. Think of all the people who wanted to be doctors and could not. You are one of those people who have that opportunity. Some have suggested, and not unreasonably, that society has invested an enormous amount of effort and money in everybody who has become a doctor, whether you attended a private or public medical school. In fact, you had taken a place that could have been occupied by someone else. So if one decides to give up medicine, it is not unreasonable to expect that person to pay back that money; to pay a tax back to society for not utilizing this remarkable tool that one has been given a chance to utilize. Try to think how many people would have gone to medical school if they could have, and how lucky you are to be one those who did.
Eight on my list of nine strategies is to be a mentor. There were people who were your mentors. These days people often talk about their one mentor. It is very unlikely that you had one mentor. You have probably had many. Think about them. Who were they? In my life, there was Dame Professor Sheila Sherlock, the liver queen from England, with whom I had a chance to spend a period of my early professional life; a person who was enormously charismatic and helped me to develop the beginning of my academic career. Charles Aring, the neurologist at the University of Cincinnati, who was the role model whom I was copying when I decided to become a neurologist. Another is Raymond Adams, who was my mentor when I was a resident. People often have personal mentors, professional mentors, and mentors of other types. My parents were my earliest mentors. Louise Elconin, my junior high school home room and English teacher, was another. Ray Nisius, my Latin teacher was another. So was Ray Warner, my football coach. Kaarlo Mackey, my high school band director, my wife, Susan Pioli were all my mentors. Eugene Braunwald, the great cardiologist, who gave me the opportunity to lead Neurology at the Brigham, was another one. There were, and are, many others. Think about them. Those are the people who passed the baton to you, and now it is your responsibility to pass the baton to the next generation. You should have mentees; people whom you are helping in one way or another to carry the glory of medicine forward into the next generation. Think of yourself as a bridge – a bridge from the past to the future. Without you, there will be no conveyance of this precious information forward. So if you ever think that you are not important or effective, realize for a moment how critical you are in passing this baton from the generation behind us on to the generations that will follow us.
Finally, the ninth point of my nine strategies for avoiding burnout is to be realistic. Frustrations and challenges are part of life. They are part of everyone’s life, but in particular, they are part of a life in which you are dedicated to the extremely complex phenomenon that is biology and the treating of diseases. Overcoming these frustrations is what a professional does. And you are a professional!
In summary, burnout is an old concept. It has been modernized and has become almost an obsession of young physicians. It is characterized by exhaustion, depersonalization and a feeling of inefficacy; all of this despite the fact that physicians in the United States are the highest paid, most prestigious, and most secure of any profession. Given that paradox, what can one do to bring into perspective the real value of being a physician and avoiding the perils of burnout? I have articulated different ways of doing this. Think of yourself as a professional whose main function is altruism – putting other people’s interests ahead of one’s own. If you do this I think it is very likely that you will not suffer from the symptoms and signs of physician burnout.
Nine Step Program to Combating Physician Burnout
Be a Professional
1. Work and learn in a truly resource limited environment but don’t be condescending
2. Empathize with your patients but don’t expect empathy for you in return
3. Spend less energy on “mindfulness” and more time on developing a theory of the mind; work is life and life is work
4. Appreciate irony and cultivate a sense of humor; don’t take yourself too seriously
5. Collect one’s own mistakes and share them but don’t expect them to stop happening
6. Study history; you aren’t that special
7. Stop feeling sorry for yourself. Realize how lucky you are to be a doctor. Others wanted to be there.
8. Find a mentor and be a mentor; you are bridge from the past to the future
9. Be realistic; no one can do everything well and stuff (sh__) will happen
Martin Samuels is the Chairman of Neurology at Brigham and Women’s Hospital in Boston and a regular contributor for THCB.
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