A Revolutionary Old Vaccine For Physician Burnout

By MARTIN A. SAMUELS, MD (8)

Burnout has become an obsession in the medical profession.  I am almost 75 years old and am not feeling 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 to offer some advice as to how to avoid this problem.

My approach is fourfold.  I shall begin by reviewing the definition of burnout, emphasizing physician burnout.   To address the individual issues, I think it is important that we are all on the same wavelength and are using the same definitions.  Secondly, I will review some facts about the reality of American medicine as we now experience it.  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.  

 Burnout is not a new idea, and it is not specific to medicine.  It has been in the psychiatry literature for quite a long time, but it was brought to our attention in medicine in a series of papers by Zeev Neuwirth, who, at the time, was an internist at the Lennox Hill Hospital in New York.  He wrote several papers on related subjects and published an article in the lay press in 1999 that was entitled “The Silent Anguish of the Healers.”  Since that time, it has become evident that “burnout” is an important issue in medicine that needs to be addressed.  Neuwirth and others have defined ”burnout” as a feeling of complete emotional exhaustion characterized by cynicism, depersonalization and perceived ineffectiveness.

An Epidemic of Dissatisfaction

In recent years, many have argued that “burnout” is extremely prevalent; not only in society in general but especially 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; especially controls from others in the learned professions.  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 prevalent 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.

The Origins of The Epidemic

What are the alleged causes of “burnout?”  There are many, of course, but there are five major categories that I shall mention and then deal with each separately antidotes.  The first of these five is what is termed “overwhelming demands and work overload” often associate 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, athletic endeavors, artistic endeavors, hobbies and others?  The third of the causes of “burnout” is the lack, or perceived lack, or loss off various resources.  In the context of medicine, this might be inadequate information systems, physicians’ assistants, nurses, clerical support, and so on.  The fourth cause is “insufficient rewards.”  Rewards 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 a zeitgeist, or a spirit of the times.  Many groups, defined by multiple criteria, feel marginalized.  This might be a religion, a racial group, a gender orientation, and so on.  One can easily recognize this phenomenon by simply reading the lay press, which reflects that 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 allegedly:  overwhelming demands, social conflicts, including work-life balance, lack or loss of resources, insufficient rewards, and absence of fairness.

The Suicide Link

It is important, in this context, to mention 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.  For several sociological reasons, it is likely 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 it is clear is 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 am I Even in Medicine?

Why do people go into medicine?  Many physicians like to argue, in retrospect, that they went into medicine because of an innate and deep desire to help others.  In 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 look at 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.  Furthermore, the gap between doctors and the number two position which is the military, is enormous; a larger gap than separates any of the others in the top ten.  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 can do so.

The Paradox of Physician Pay

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 many years.  These data are reported as median salaries, which is the best way of analyzing this issue as it means that half of all those in each 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. 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 some clearly pursue medicine for this reason, the truth is that medical students are people who have entered medical school in enormous competition with others because they can succeed at tests and obtain high grades.  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.  That means that people going into medicine are not doing so necessarily because they want to help people.  They are probably pursuing medicine because they can.  Any why?  Because it is a job 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 prerequisite 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 measure and 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.

The E Word  

With this prologue, 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 whatever other aspect of life they wish to pursue.  This includes family life, athletics, music, literature, art; whatever they care to pursue.  These are people who have been used to getting all As, 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.

A Brief History of Professionalism

So, what are the antidotes for “burnout?”  To develop antidotes for burnout, it is worthwhile to think back at what it means to be a profession.  Many scholars over the ages have considered the characteristics of a profession.  Justice Louis Brandeis voiced some 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.  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 which 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.  The major antidote for burnout is to be a professional.

Developing Immunity to the Disease

I shall outline a nine-point strategy for avoiding burnout, all of which have in common the unifying theme of professionalism.  The first point of my nine-point program is to try working in a truly resource-limited environment.  When you do 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 can 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, who is one of my colleagues at the Brigham and Women’s Hospital in Boston, and the book by Tracy Kidder, “Mountains Beyond Mountains,” written about Paul farmer and his work.  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 economically 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 fact, it is often 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 to be 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 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 and we go there on a regular basis to provide neurological consultations.  When one returns, one has learned how it is possible to practice medicine very effectively in a resource-limited environment, and one feels 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 this phenomenon of “burnout.”

The Empathy Trap

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 argued 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 better.  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 offended by the fact that their patients do not necessarily share their own, perhaps progressive, 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 way patients talk to 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.  

Focus Outward / Not Inward

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.

Laugh at Them, You’ll Be Happier

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 hospitals 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.  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 already 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 cobranding 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 toe 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 cobranding 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 palaceholder 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 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.

It could be useful for me to elaborate on a couple of specific examples in my own personal career in which humor helped me to ameliorate frustration, discouragement, and alienation, all of which have been said to be components of the “burnout” phenomenon.  Here are two such episodes.

Once Upon a Time in a Hospital That Shall Remain Nameless

I was a young doctor building a new neurology service in a hospital that was part of a large hospital chain.  CT scanning had entered and transformed many aspects of medicine, neurology included.  Nearly all centers had access to CT scanning but my hospital did not.  The administrators were waiting to see whether it would “catch on.”  They hoped that they could get away without the expense of buying a CT machine.  It’s funny in retrospect to think that the leaders of this hospital, even in the early 1980’s, could have imagined that CT scanning was something they could live without, but that was the fact.  I was very frustrated and angry.  I was unable to practice the brand of neurology I had been trained to practice and I was unable to offer my patients what I thought they needed.  For example, to visualize the spinal cord, we had to inject air into the subarachnoid space and use conventional X-ray; a painful, crude and outmoded technology, called pneumoencephalography.   Finally, after about seven years of entreating the authorities, the leaders of our hospital agreed to share in the purchase of a CT scanner on a truck that would drive from hospital to hospital within the hospital chain.  One could order CT scans one half-day a week when the machine was at our hospital.  The day it arrived was an exciting one.  Finally, we were about to enter the CT era, just in time for MRI to displace it as the cutting-edge imaging modality.  Still, we were delighted to have this new instrument, even it was for only a half-day per week.  On the first day, with the first patient in place, I was given a tour of this “cutting edge” facility.  I had a cup of coffee in my hand, as I often do in the morning.  As I leaned over the computer terminal, I accidentally spilled the entire contents of my cup into the key board.  There were a couple of sounds, and the thing went chunk-ka-chunk-ka-chunk and stopped.  The entre screen turned to all x’s.  I had broken the CT scan before the very first patient was completed….and after a seven-year wait!  It was a horrifying moment.  One could have been very discouraged.  But think about the irony there.  We had taken seven years to get a technology that we should have had so long before and I was one of the greatest proponents of this.  And then, I was the one to immediately broke the scanner!  It had to be sent back to the wherever it was built and it put us off another three or four months before we got the CT scanner back at the hospital.  Still I think of it as humorous and ironic in a way.  The great proponent of CT scanning would immediately break the CT scanner the moment it turned up!

The Administrator Will See You Now

Another anecdote underlines the idea of seeing the humor in something that is otherwise rather frustrating.  When I arrived at a hospital as a faculty member, there were not enough conventional offices to go around.  So, the leaders of the hospital found a toilet, a bathroom, that they decide would become my office.  The only two useful devices in the little room, the toilet and sink, were removed, leaving a barren room with tile walls.  It did have one window, but it, of course, was opaque as this was formerly a toilet.  And that was my office.  So, to make it more tolerable I went to a discount chain and bought a pseudo-Persian rug, which cut down on the echo from the tile floor and walls.  But, I was immediately told that this rug was not allowed because it did not meet specifications and was not bought from the authorized dealer, so it was removed.  I then asked that they replace the glass in the opaque window so I could have some light.  The response was that the central administration had disallowed this request because there was a plan to replace all the windows in the entire hospital.  It was not authorized to replace any glass until all the glass in the building was replaced.  I inquired about the estimated timing and was told it would be about two years, which in this hospital system, meant at least five years.  A perfect scenario for burnout; disrespected in a little toilet and not even given the capacity to soften the sounds and have natural light.  But there is humor in this.  One night, on my way to my car I came across some young men from the local high school who often hung out in this location.  I went up to the group of these young fellows and I said, “you see that opaque window up there?  Do you think any of you could throw a rock through that window this weekend?”  “Oh yeah, that would be easy, but why would we want to do that.”   “We’ll, here’s 10 bucks,” said I.  When I came to work on Monday, I was shocked (as was Captain Renault in Casablanca) to find my window shattered.  It had to be replaced.  If the administrative people had been clever enough to realize what had happened there, they could have replaced my window with opaque glass.  But, alas, they did not and from then on I had a lovely view and natural light.

The Perfectionist’s Dilemma

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, I believe you should share them with your close colleagues.  No one must act like a “superman.”  Some years ago, one of my longstanding 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 summary 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, 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 developed by Richard Dawkins and Susan Blakemore.  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 loftier 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 happening 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, it is an idea; an idea that reproduces itself.  Dawkins makes the point that women’s right to vote was an idea (a meme) which 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.  Now 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 (i.e. go viral).  These rare events are not necessarily good things.  Some of them are bad, frightening ideas, like a new viral disease, such as Zika or COVID-19.  One can witness the memes about COVID-19 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 as copying itself.  

Mistakes are Good, Not Bad

This means that mistakes are critical for progress in medicine, as medicine is based on ideas.  As an example, I was trained by an eminent neurologist named 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 line back to John Hughlings Jackson, an eminent neurologist in London in the 19th century.  If there were no changes in the memes, 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 much less facile than Hughlings Jackson 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 be the same, 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.  

Mistake-Based Medicine

I summarized this in an essay which 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.  Thus, there will be continuous errors, most of which will not hurt anyone, nor will they likely be helpful.  Occasionally the errors may lead to a new insight or a new treatment or sadly a bad outcome.  This process is involuntary and is always occurring.  During a change, we cannot see it.  One can only appreciate these after a long time has passed, probably decades at the least.

The Power of Time and Place

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 fact, this is an illusion.  Think back to when Von Leuwenhoek first gazed down his compound 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 did believe this, and 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. 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.  I trained in internal medicine before going into neurology at Boston City Hospital, a giant hospital in the center of Boston with a very distinguished history of training academic physicians and taking care of the poor.  It was a very difficult place in which to work.  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.  Many 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 biggest 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 when I had had 10 or 12 admissions and everything was going badly, I cannot tell you how much inspiration this memory would give 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.  It is likely that our current challenge of COVID-19 will generate new memes about the prevention and treatment of epidemic viral illnesses.  As we are now amid the change, we cannot appreciate it.  Think of the beginning of the HIV challenge and compare it to what we think of that virus today.

Over at the Brigham, where I have spent much of my career, 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 hemoglobin would drop and they would inevitably die of the horrible disease known as Addisonian, Biermer’s or pernicious anemia.

George Minot and Williams Murphy were two hematologists who had 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 institutional review board (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 raw liver.  I have 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 1935 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 one of 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.  He describes the people coming in droves, often in extremis.  There Minot and Murphy sat by their 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 medical research. 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, to help others.  This memory is inspirational and energizing for me.  Now an analogue of this experience is occurring with COVID-19.  Study history.  We are not that special.  People have been there before us.

Remember to be Happy

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 has 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 are taking a place that could have been taken 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.

Mentorship

Eight on my list of nine strategies is to be a mentor.  There were those who were your mentors.  Today, people are 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 the U.K. where I had a chance to spend a part of my medical education; 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 becoming a neurologist.  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.  Think about them.  Those are the people who passed the baton to you, and now it is your job 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 passage of this precious information forward.  So, if you ever think that you are not important or effective, realize for a moment how important 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, especially a life in which you are dedicated to the extremely complex phenomenon that is biology and the curing of diseases.  Overcoming these frustrations is what a professional does. And you are a professional!

In summary, burnout is an ancient 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 even though 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.  All of them are various pathways of approaching a specific problem, and that is to try to think of yourself as a professional whose main function is altruism; putting other people’s interests ahead of one’s own.  If you do all of this I think it is very likely that you will not suffer from the symptoms and signs of physician burnout.  

Martin A Samuels, MD is Chair Emeritus, Department of Neurology at the Brigham and Women’s Hospital and Miriam Sydney Joseph Distinguished Professor of Neurology at Harvard Medical School.

8 thoughts on “A Revolutionary Old Vaccine For Physician Burnout

  1. I am not a doctor, I am an engineer, which I do because I love the work. Where I live engineering pays very well, better than most doctors, but I have always said that (while great) pay is not even a fraction of the reason I choose to be an engineer.

    Right now I work on a very arduous project that often has me up at as late as 2am in the morning keeping up and planning ahead, but I don’t feel badly about this, I see an opportunity for success and triumph is available. It could only be like this because I am doing something I find personally rewarding.

    I see most of the physician burn out articles as being narcissistic pity pieces – for almost all it was choice to become a doctor, and well rewarded financially and respected by society. This does not necessarily come easily, and nor should it. And it is accompanied by a social responsibility to use the abilities and training for the greater good. And sometimes that might mean you are stretched to your limit – but the ability to do this is part of what makes humans the dominant species on the planet.

    The ability to take this stress and turn it into, or associate it with, pride because you are doing your most and best at something that is helping others in need, should be able to sustain you most of the time if you have chosen the profession for the right reasons. As the article says, a fair weather physician is robbing society of the return on the investment granted to that individual and blocked someone else that may have had more chops.

    I think this is one of the best pieces of writing about physician burnout I have read, by a country mile, but also fantastic piece of writing on all it’s own.

    Not only that, I think it is so eminently accessible and relatable in such a way that it has something to offer all professionals who care to contemplate it.

  2. This piece is really good — and I’m only about a third the way through it. In my mind (for whatever that’s worth), I see the physician burnout issue as contagious. It seems like it’s in vogue to join the “burnout” club. Maybe it’s just because my Twitter stream is healthcare heavy. Regardless, I see a whole of talk of the problem and not nearly enough action fixing it by those who are affected. Life is a pain in the ass for most everyone. 🤨

    Great blog by the way John! There’s a lot of deep diving going on!

    1. Thanks Clay!

      I strongly agree with a lot of what Marty has to say. And strongly (make that violently) disagree with some.
      That’s a sign of a good piece in my book

      I’ve always been surprised by the total disconnect between the way working physicians see themselves and the way others see them.

      Hospital administrators, journalists, lawmakers, some in academia and too many “consumers (I hate to use the word consumers, but its the word we use for now) have somehow come to see physicians as overpaid babies who have a cushy life. This is a narrative that dates back 30 years to a time when doctors did have relatively easy lives and lived at or near the top of the social pecking order. Throw in health plans who see doctors as a threat to their profits and tech companies that want to market tools for doctors but don’t seem to understand how doctors work and you have a very strange political landscape.

      This culture clash is the reason we’re in the place we are today.

      I’m actually fairly optimistic that COVID-19 is going to change things. Doctors enjoy greater public support than at any time in recent memory.

      Will that shift lead to change in the balance of power?

      I certainly hope so.

  3. I should start by commenting that I know Dr. Samuels to be a brilliant teacher of neurology. I avidly attend his lectures at the annual American College of Physicians meetings. Not only are they enlightening but entertaining and humorous. I look forward to them in the future.

    The Dr. Samuels I know would likely agree that in order to treat a condition one should understand it. Though his commentary is entertaining and thoughtful, it leads me to wonder whether being Chair of Neurology at Brigham and Women’s might isolate one from the realities of life in “the trenches” of modern American medicine.

    Most importantly, Dr. Samuels fails to recognize burnout as an emotional condition like anxiety or depression, both of which are likely components. He seems to want to grab America’s doctors by the lapels (or blouse) and tell us to “snap out of it.” This is a bit like reminding depressed patients that their lives are far better than those of their ancestors going back for millennia: objectively true but not a very practical nor helpful insight. Rational self-analysis is just not the coin of the realm for burnouts.

    Perhaps the major issue in physicians’ burnout is the loss of control over their work lives. An AMA survey last year showed that for the first time, more physicians now are employees rather than being self-employed. The trend is likely even stronger for younger doctors. Working long hours and dealing with pain and suffering are probably more tolerable when one has autonomy and control over one’s work conditions. It’s hard to take refuge in the status of a professional as patient time shrinks versus that spent on insurance authorization requests and the enormous documentation demands of modern electronic records.

    Yes, humor helps. Dr. Samuels accurately and hilariously skewers “management speak” in his paragraphs of satire. But how funny would it be to have one’s day to day practice life and one’s fate controlled by the purveyors of that brand of verbal techno- garbage?

    Dr. Samuel’s story of the young doctor and the window offers us a parable on the issue of autonomy. His willingness to throw a rock through his office window to get it changed (and his Harvard law colleagues with their concept of agency might put it that way) provided him with a way to assert his independence. Many of today’s doctors don’t even have an office let alone a window. They practice in “bullpens” like mid-level office workers. In comparison, a bathroom office has some redeeming features

    Moreover, some of Dr. Samuels’s facts are just off. I won’t bother to do the internet search to prove it, but the idea that ENT doctors and Ob-Gyns make less than internists is a bit laughable. In my urban area they probably make about twice as much.

    Yes, doctors earn more than average workers. But Dr. Samuels might consider that from college until the start of practice, a primary are doctor pays tuition for eight years and then is grossly underpaid through three years or more years of residency. The average medical graduate now enters practice with $200,000 of debt which would be another full year’s salary. And housing? If the new internist wants to buy an average home in Cambridge, in Dr. Samuel’s part of the world, Zillow tells him/her to expect to pay over $800,000 or another four years of pre-tax salary. Given the long delay in earnings, the burden of debt and the level of compensation, particularly for the non-procedural specialties, physicians are very far from the windfall income that Dr. Samuels suggests.

    For my own part, I still share Dr. Samuels’s appreciation for the gifts of this extraordinary profession. Yet I also recognize that the profession has changed. The conditions that once largely compensated for the great sacrifices made by practitioners have changed profoundly in ways that Dr. Samuels seems to have missed. To fail to recognize these changes and to see “entitlement” in the emotional struggles of our colleagues is to pursue the wrong diagnosis.

  4. There’s so much to love (and love) in this essay.

    Another definition of a profession is a discipline that’s in control of its tools. It’s what separates the doctors from the technicians, or at least it used to. The loss of control threads throughout Marty’s essay. That same administrator class he describes so effectively, figured out decades ago how to inject technology they control in the form of Electronic Health Records directly into the heart of the physician-patient and physician-physician relationship. The telltale antenna looks like a mouse and screen connected to a black box of proprietary code designed to control people.

    Who learns of and from the mistakes? Who decides what is a mistake? The black box connects us to Madison, WI in mysterious ways. Secrecy, protected by law as “intellectual property”, optimizes each patient encounter as the hospital and the vendor split the profits. How does this square with Marty’s concept of a profession as altruistic?

    Technology has advanced to the point where each physician and each patient carries almost a thousand dollars of it in our pocket. A patient’s cloud accounts hold quantities of personal pictures and videos that make an MRI look small. Open source software, like Mozilla Firefox, is accessible for peer review and free to use and improve just like clinical medicine used to be.

    The medical profession can take control of its tools. We start by insisting on open source EHR software, as Mukhergee demands in the recent New Yorker piece about resilience in the face of a pandemic https://www.newyorker.com/magazine/2020/05/04/what-the-coronavirus-crisis-reveals-about-american-medicine . Also, we honor the patient’s choice of where their health records are kept and who gets to access them, and who gets to learn from the mistakes. Together, these two complementary steps, remove both the hospital and the black box vendor as middlemen and restore the essence of a profession.

  5. Dear Dr. Stone:

    Thank you for commenting on my essay and thanks also for the compliment on my presentations at the American College of Physicians (ACP) annual meetings. I am very proud to be a Master of the ACP and feel it is the best advocate for internists. As you may know, I trained in Medicine at the Boston City Hospital and in Neurology at the Massachusetts General Hospital so my interest has always been the interface between these two disciplines which are cousins in many ways. Unlike most academic department chairs, I am exclusively clinical though we have a great deal of research going on in the department. After 30 years in that role at the Brigham and Women’s Hospital I stepped down from the chair nearly two years ago, but continue my non-administrative tasks such as seeing patients and teaching students, residents and post-graduate doctors. I have been intimately affected by the changes in medicine that you describe and I have seen many of the deleterious effects. My essay is an effort to afford doctors some perspective on how one might avoid “burnout”, which I agree is a version of depression and anxiety in the face of hard or impossible to control external forces, as Dr. Gropper points out in his essay.

    I know I am supposed to argue with your views, but I find that we are almost in complete agreement. Medicine has certainly changed and much of what has happened is the corporatization of the profession. Loss of control of one’s working environment, as Dr. Gropper states, is definitely part of the problem.

    The statistics about salaries were taken, as I said, from the US Department of Labor Statistics and those about the perception of doctors by the general public from the Harris Polling Organization. I agree some of them seem odd to us as it is not the way we think about the different disciplines of medicine, but the main points of my essay are not based on those numbers. When we chose our specialties, we all knew that neurosurgeons, vascular surgeons and ophthalmologists made more than internists, pediatricians, neurologists and psychiatrists. I agree that this disparity is not fair, but we knew these facts when we made our choices. More importantly, all fields of medicine allow for a decent living and overall are better in this respect than virtually all other endeavors. The same can be said for job security. Housing is expensive in the Boston area, but I don’t live in Cambridge where the main Harvard University is located. The Harvard Medical School is in Boston and Allston. We live in the South End which is very quaint. We love it but it is not ritzy. I rented an apartment on a $9,000 annual income from Boston City Hospital and three years later bought a condo in Back Bay for $60,000 by borrowing the $15,000 down payment and taking a $45,000 mortgage. Even accounting for the increase in property value and inflation, the analogous scenario can be done today.

    I agree that burnout is not an external problem but an internal experience akin to depression, often with anxiety. Psychotherapy and sometimes prescribed medications can help, but the ultimate solution is to learn to cope with the changes. Changes are always happening and one of signs of cognitive decline is reminiscing too much about the past. I am no exception, being a Clevelander, I pine for the 1964 Browns (I was there in Municipal Stadium when they upset Jonnie Unitas’s Colts) and the 1948 Indians (I have the pennant, but alas I don’t remember the event as I was only three years old). The antidote to burnout is to look outside of oneself and look forward; not backwards.

    Thanks again for taking the time to respond to my essay. Please come up and introduce yourself at the next face to face ACP meeting. Perhaps we can continue the discussion over a beer. Dr. Gropper, I don’t know if you will be there, but the invitation includes you.

    Sincerely,

    Marty

    1. Thanks, Dr Samuels, for taking the time for such a thoughtful reply.

      The offer of continued discussion over a beer at the next annual ACP meeting is tempting. I was quite disappointed that after over 30 years of attending, the first meeting in Los Angeles, my home town, was canceled due to the corona virus epidemic. Orlando in 2021 is less tempting but your kind invitation will provide some incentive

      Best regards,

      DS

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