As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His seminal piece, “A Flag In The Wind: Educating For Professionalism In Medicine”, seems written for today.
Nearly two decades ago, Inui keyed in on words. In our modern world of “fake news”, concrete actions carry far greater weight than words ever did, and the caring environments we are exposed to in training are “formative”—that is, they shape our future capacity to express trust, compassion, understanding and partnership.
Inui reflected on the varied definitions or lists of characteristics of professionalism that had been compiled by multiple organizations and experts, commenting:
my own perspective, I have no reservations about accepting any, or all of the
foregoing articulations of various qualities, attitudes, and activities of the
physician as legitimate representations of important attributes for the
trustworthy professional. In fact, I find it difficult to choose one list over
others, since they each in turn seem to refer largely to the same general set
of admirable qualities. While we in medicine might see these as our lists of
the desirable attributes of professionalism in the physician, as the father of
an Eagle Scout I know that Boy Scout leaders use a very similar list to
describe the important qualities of scouts: ‘A Scout is trustworthy, loyal,
helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean,
reverent (respecting everyone’s beliefs).’ I make this observation not to
descend into parody, but to make a point. These various descriptions are so
similar because when we examine the field of medicine as a profession, a field
of work in which the workers must be implicitly trustworthy, we end by
realizing and asserting that they must pursue their work as a virtuous
activity, a moral undertaking.”
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.
Throughout history, physicians have treated patients for conditions that generations of their professional successors later deemed figments of their (the physicians’) imaginations. The list is long, but in just the last 100 years, it has included such disorders as female hysteria, homosexuality, moral insanity, neurasthenia, and vapors, among many others. The consequences of such diagnoses were not trivial, and in some cases, patients were stigmatized, ostracized, subjected involuntarily to a variety of noxious treatments, and even incarcerated because of them. Yet we now believe that each of these conditions was a fiction, and they are absent from today’s textbooks.
Something similar may be afoot in the profession of medicine today. The affliction is known as conflict of interest, and medicine is thought to be suffering a pandemic of it. In fact, its proponents argue that no physician is safe. Its symptoms among researchers are a tendency to conduct investigations and publish results that are biased, and among clinicians, to prescribe tests and therapies that their patients do not really need. The underlying cause of the condition is thought to be financial inducements from industry, which lead these gullible physicians and scientists to betray their personal and professional integrity without even knowing it.
For example, industry funding of research might lead physician-scientists to bias their results in ways that line the pockets of pharmaceutical companies and medical device manufacturers. Likewise, the presence of industry representatives in offices and hospitals might lead physicians to write inappropriate prescriptions for industry-promoted drugs. If physicians are presented with a gift such as a pen, a notepad, a book, or a free meal from an industry representative, they might be more inclined to use that company’s products in their practice. The implication? Physicians are insufficiently self-aware and trustworthy to put patients’ interests above their own.