Burnout: Etiology or Symptomology?
I went to a breakfast seminar on physician burnout this morning. If you are not a part of the medical world or are otherwise foreign to the idea of physician burnout, suffice it to say that it is a descriptor for a syndrome of cynicism, lost enthusiasm for work, and lost sense of accomplishment that this year affects more than half of American physicians. I’ve been to a few of these burnout seminars in recent months – partly because I would like to harvest some “pearls” from elder physicians on how to avoid this disease of the modern doctor, and partly because this series of breakfasts has been hosted by the American Public Philosophy Institute, a ministry of sorts out the University of Dallas which attempts to address important issues in public and professional life from a Catholic perspective. Given that breakfast and reflective conversation is a lovely way to spend a Saturday morning, I have also been especially curious as to whether the Christian religion has something unique to say about physician burnout, to see if it can offer some inventive solution that the secular medical community has – as of yet – been unable to discover.
Inevitably such conversations turn to perhaps the most important and fundamental question of this topic: what is the etiology – an appropriately medical term – of burnout? I suspect we have already erred in forming the question this way, as it seems to me that physician burnout is almost certainly multifactorial. Regardless, physicians across America (and likely the rest of the world) are striving to get to the root(s) of the burnout problem. Interestingly, whenever I hear the question of etiologies raised, those involved in the discussion struggle to find a unifying theme amongst the causes, and speak mostly in metaphors, examples, and experiences, perhaps hoping to illuminate their deeper truths.
“Burnout is when Sally B. and Tommy Q. and Johnny Z.* become ‘the pathological fracture in room 4’, ‘the pancreatitis in room 6’, and ‘the psycho-social nightmare in room 666,’” you’ll hear them say. “Burnout is when medicine is no longer as rewarding and fulfilling as it once was” or “… as I thought it would be”.
On a scale of 1 to 7, respondents to the particularly illuminating Medscape Lifestyle Report rank the top 5 causes of burnout as “Too many bureaucratic tasks” (5.3), “Spending too many hours at work” (4.7), “Feeling just like a cog in a wheel” (4.6), “Increasing computerization of practice” (4.5), and “Income not high enough” (4.1). If your intuitions are anything like mine, taking the conversations in which I have participated and have overheard together with the Medscape survey, it is immediately apparent that some of the proposed “causes” appear much more like symptoms, at least plausibly. It seems insurmountable to discern, and much more so to study, which of these ambiguous answers (“feeling like a cog in a wheel”, for example) are causes of burnout and which are its effects. In fact, while we are ruminating on the complexity and the grey of physician burnout, let us not forget to admit that some may be both a cause and a symptom.
So which came first – the chicken or the burnout? And what patterns can we perceive in the many suggested causes of this epidemic? What uniting ideological problems might contribute? If there is anything I am sure of, it is that I cannot alone give a full answer to these questions. However, some recent experience may illuminate at least a partial solution.
Still Burning: A Case Report
Yesterday I completed a rotation in the Pediatric Hematology & Oncology clinic at my institution. In my anecdotal, subjective, and entirely statistically (but not meaningfully) insignificant experience, burnout has a prevalence of much, much less than the 47-51% expected in such a department. In fact, the two most senior faculty members I was privileged to work with each at one moment or another made remarks much akin to “This is the best thing you could ever possibly do with your life and I would never do anything else.” This, mind you, after a combined 60+ years of practice in a medical specialty which all-too-often watches innocent children suffer and die as their own bodies eat them from the inside out.
Moreover, the physicians I worked with accomplish this feat without any noticeable detachment or depersonalization. In this department it is not “the pre-B ALL in room 10”, but little Juan*, whose leukemia just relapsed post bone marrow transplant. It is not “the osteosarcoma in room 13”, but little Emily*, whose chest CT just came back with diffuse metastatic lung disease. I watched more than one of these good doctors, male and female alike, become tearful at the arrival of damning test results for one of their patients, to which their colleagues would respond with empathy, solidarity, and a consoling touch. If there were not tears for bad news, without exception there was at least the verbalization of sadness, and never cold indifference. They would then stand, take a deep breath, and go to suffer with (compatī) the sufferers (patiens).
Yet minutes later the atmosphere in the command post would return to its normal, jovial state, with pleasantries and jokes, smiles and laughter all around – and this not for lack of caring for the patient, but for abundance of caring for each other. As a traveller, just passing through on my journey to Medicinae Doctor, I was sucked into their community like a pilgrim at a friendly road-side tavern, almost to the point that I became suspicious it was all a big joke, that the conversation and food and teaching was only because I was walking around with a “Kick Me” sign on my back.
How? How was this possible day in and day out in the face of the death of children? Or worse, the dying?
I have a few suspicions.
An Extended Metaphor
I operate under the belief that the words we use are important. Broadly, words typically have a rich history and context which give them deeper meaning (see the nod to the precursors of compassion and patient above), and will no doubt journey on to new and distant places yet (I can’t wait to see what volatile words like evangelical, liberal, and Tex-Mex mean in 10 or 20 years, for example). Nowhere is this truer than in regard to idioms, figures of speech, and other metaphorical or symbolic language, burnout included.
The word evokes the image of a candle or a gas lantern. When a light such as these burns out, it is implied that there was a fuel source which was used completely, and thus we have the modern connotation that burnout is somehow related to fatigue; rather than wax or gasoline, the burned out physician has exhausted his own internal energy reserves, be they physical, emotional, or spiritual. This is probably part of the truth. However, I submit to the reader that the burned out physician may have never caught fire in the first place, for lack of the right kind of fuel. Imagine, for example, that your candle is made of steel or your lantern is supplied with water. It wouldn’t take very long to burn out, would it?
The Pediatric Heme/Onc team I worked with these last two weeks, I think, is fueled on love. This is why almost every doctor in the department seemingly continues to burn bright. Personal fulfillment, the gratitude of patients, and feeling more significant than “a cog in a wheel” are for them the steel, the water, the golden calves set aside for a pure and unconditional agápe toward the sick children. They have found the secret: if you try to run your life on fulfillment and gratitude, there will never be enough. The tank will eventually be on empty. I fear that we – myself included – have at the outset of our careers idolized the profession of medicine to the extent that we believe participation in its practice alone will bring happiness, meaning, even salvation. Could it be that much of physician burnout is the slow realization that the practice of medicine does not save the practitioner’s soul, does not give ānanda, does not reach nirvana? (Which, interestingly is the Sanskrit word for the burning out of an oil lamp.)
Now let us assume we have the right fuel: the wax, the oil, the love of the patient. A candle, we know, can only burn so long before another candle must be lit; if the wax is replenished, however, and candle after candle is offered, the flame is eternal. This too was made manifest in the oncology clinic these last two weeks. Their flame was nourished in a caring and supportive community, a community that does more than just show up for work. I heard countless conversations about personal struggles and family difficulties, all solicited by an interested co-worker and friend.
This lived community is not limited to the workplace for these people. Once a week in the evening after work, as many fellows and faculty as are able gather at a faculty member’s home for what they call “journal club”, but is like no other journal club of which I have heard. Each week on the day following “journal club” I was able to piece together a recounting of what might best be described as a feast – not only of food and wine, but also of knowledge and good company – lasting deep into the night. It was overwhelmingly apparent how refreshing and uniting this meeting is for those who are able to attend. If there is to one day be formal physician burnout therapy, allow me to suggest such feasting as the first clinical trial.
I will note that in my Southern Baptist upbringing we described such a gathering as fellowship.
Plan of Care
Please do not hear what I am not saying (though I fear if you have done so it is entirely my fault for not making my case more clearly). I am neither denying the existence of burnout, nor stating that the burned out are the unenlightened and the selfish, nor prescribing the de-idolization of medicine as a silver bullet cure-all. What I am suggesting is that salvation is not found in the practice of medicine, nor in its nobility, nor in “fulfillment”, and (at risk of stating the obvious) nor in adequate compensation. I am suggesting that a paradigm shift which views patients as intrinsically infinitely valuable, as brothers and sisters in humanity, to be loved for their own sake (dare I use the words “holy” or “children of God”?), may be some small part of the treatment for burnout. And I am suggesting that efforts to bring healthcare professionals together to be refreshed and renewed in community with one another make for an excellent means to sustain a love for the patient.
In the Christian gospels, six times Jesus of Nazareth repeats some variation of the theme that “those who try to save their life will lose it, but those who lose their life will keep it”. From a historical-critical standpoint, to have been included in the four gospels so many times in so similar a manner indicates that this teaching and the passage surrounding it was a matter of greatest importance, both to the man who some people call The Great Physician and to the communities who recorded his teachings. May those of us who heal the sick lose our lives in a love for our patients that never burns out.
Admittedly, fewer “bureaucratic tasks” would be nice as well.