"The afternoon knows what the morning only suspects."
"The longer I live, the more I am satisfied of two things; first, that the truest lives are those that are cut rose-diamond fashion, with many faces answering to the many-planed aspects of the world about them; secondly, that society is always trying in some way or other to grind us down to a single flat surface. It is hard work to resist this grinding down action." - Oliver Wendell Homes M.D.
Career burnout, like many other labels, is a somewhat dubious amalgam of substance, mask and fallacy. In the month prior to writing this piece:
Catchy and evocative as the term ‘burnout’ may be, it risks ending up one more empty-vessel word in our vernacular, for can it be all of diagnosis, clinical description, clinical syndrome or symptom? As examples of its limitations, consider:
To move from what career burnout is not to what it may be, we need to establish an operational definition.
Career burnout is typically considered to consist of a triad of:
In the case of burnout among physicians, I feel that additional clarity is provided by stating that--
This leads to the following operational definition:
Physician burnout is a condition of over 3 months duration where a previously high functioning physician experiences physical and mental exhaustion, disengagement from the human service component of their work, and diminished accomplishments at home and at work. These elements arise de novo, in persons whose previous work record was exemplary, and are not signs of a pre-existing psychological disorder.
Career burnout in physicians can be usefully classified into two broad categories, primary and secondary, based on the etiology of the difficulty.
Primary career burnout arises from career choices made by the individual themselves, and are largely independent of their practice milieu or prevailing currents of change in medicine today. These physicians need to focus on a significant redirection of their professional energies.
Physicians with secondary burnout experience the problem due to the interactions of their natures with their employing organization or practice, sometimes leavened with the influence of professional culture. Maslach, identifies six primary personality characteristics of the individual predisposed to career burnout, but to my mind she’s really considering secondary forms of burnout here. These characteristics include low levels of stress hardiness, a locus of control more externally than internally derived, an avoidant coping style, low baseline self-esteem, compulsive perfectionist behavior, and being more a feeling than a thinking person.
"...these are awful times, but you must remember that this has always been the chief characteristic of the present, to everyone living through it; always, throughout history, and so far as I can see for all the days and years to come until the sun and stars fall down and the clocks have all ground themselves to expiry..." - Tony Kushner in ‘Homebody Kabul’
Experiencing career burnout can be an isolating and discouraging experience. Affected physicians commonly feel in a lonely deep hole without the toolkit to dig themselves out. A good way to begin is to dispel some common misunderstandings.
Burnout occurs when there is disequilibrium between the nature of the individual and the employing organization or practice, typically occurring at one or more of six fulcrum points identified by Maslach and co-workers - workload, individual sense of control, monetary and intrinsic rewards, sense of community, organizational fairness, and values. Our individual natures are important contributing factors but need not be the major drivers. See more on this issue in point 5 below.
The contrary is true. Burnout is more likely in individuals who came to their career and profession in the first place with high levels of energy and enthusiasm and with a history of identifiable strengths and successes.
Burnout manifests itself among doctors as much by the absence of positive emotions about work as the presence of negative ones. Practicing medicine is demanding under any circumstances – it’s easier if the physician brings engagement, energy, enthusiasm, and excitement to work each day, all qualities driven underground by burnout. Even a state of neutral emotions about our profession is enough to make it quite burdensome.
Burnout is best considered as a symptom rather than a terminal endpoint in a physician’s career. Like any symptom that is addressed early and definitively there may very well be a positive outlook. As a starting point, there is the positive of highlighting for the affected individual, their partners or employing organization the imbalance in one of the six dimensions listed above and allowing room for changing them.
Successful management hinges on extirpation of the underlying cause, while acknowledging that the severity and duration of the problem are additional confounding factors.
These physicians with primary career burnout [arising from career choices made by the individual themselves, and independent of their practice milieu] need to focus on a significant redirection of their professional energies, either moving out of medicine altogether, combining their medical degree with another discipline like law or business, or sometimes working in another medical discipline. In this category of burnout therefore, there are concrete steps that the affected person may take to work around their dilemma and career dissatisfaction.
In the case of physicians with secondary burnout, a critical examination of the role of Maslach’s six variables in an individual physician will often yield benefit. I’ve had success helping physicians move to work in practices and organizations whose value systems and rewards are more congruent with their underlying nature. I’ve worked jointly with a psychiatrist to help a physician whose compulsive tendencies were preventing finalization of patient records and communications to referring doctors. I’ve helped develop specific programs that highlighted some particular niche expertise for physicians. The possibilities are nearly endless - there is almost always a creative way to overcome the dilemma.
"The fragment of a life, however typical, is not the sample of an even web: promises may not be kept, and an ardent onset may be followed by declension; latent powers may find their long-awaited opportunity; a past error may urge a grand retrieval." - George Eliot in Middlemarch
When a middle-aged physician experiences doubts about their career choice and wonders if they would be happier doing something else, they are normal. It does not matter what quasi-pejorative label like ‘midlife crisis’ gets applied by spouse, peer, relative or friend. Midlife is a natural time to examine some of the choices we made earlier in our lives. Doing so represents a high level of sanity, wisdom and good sense.
The playwright John Patrick Shanley (an Oscar winner for Moonstuck) decried that debate a la Crossfire had become the form of communication in our society. He said: "There is no room or value placed on doubt which is one of the hallmarks of the wise man..." Read More
Many thoughtful, considerate and responsible people decide in midlife or midcareer to take inventory and make changes. Some have gone from the daily mundane to great fame. Paul Gauguin was 43 when he left the world of stockbroking and took off for Tahiti to paint and sculpt to the everlasting benefit of mankind. Others, at the height of fame, have questioned the meaning of it all. Bjorn Borg must have been hearing a proverb from his native Sweden (it’s in the byline above you), when he stepped away from competitive tennis in 1981 after having won Wimbledon 5 times in a row.
In my own case, when, at age 49, I moved out of organized medicine to pursue other ventures, I was responding to a feeling that had been percolating for at least a few years. To the not infrequent question, "are you having a midlife crisis", I would reply "no, I’ve got midlife sanity".
Some of us, through no fault of our own, our parents, families, colleagues, superiors or institutions, slowly develop a sense that some other important purpose or ideal is not being met by our current professional activities. While there may be a multitude of reasons to consider a career change, a rather common one is the emergence somewhere in our 30s or 40s of a greater sense of who we really are and a more complete cleaving from our parents By now, we’ve lived long enough to have enjoyed personal success, and most of us have also experienced disappointments and losses. In aggregate, these further shape and differentiate us.
Many of us ask questions such as:
Daydreaming as I rode an up elevator in a department store lately, I was startled to see my father looking back at me in a mirror at the top. How much I resembled this man now dead some eighteen years shocked me from my reverie. Read More
If, in midlife or midcareer, you are examining your career options, congratulate yourself. It takes courage to raise your hand and say "is this it?" I’ve known physicians make major career changes and greatly enjoy the experience. I’ve known others who made adjustments within their existing professional activity and also benefited enormously.
The gain comes from an acknowledgment that all the time you will spend at work over the next 5,10 or 15 years should be spent doing something that is fundamentally satisfying. Stepping back for a few months to reexamine your career will help.
"I’m sure most of us docs work hard and try to do the best we can. But I’m not sure we don’t hurt a lot of people with our manners, our sour moods, or the big rush we’re in. I don’t have answers. I know we’ve got a lot on our minds. I don’t need someone reminding me how tough this work is; I know how tough it is from years and years of experience..." - William Carlos Williams
Individuals we surely are but as we absorb the mantle of our profession we weave a cloth that becomes part us-part physician-persona. Disillusionment with our professional lives may emerge when there is a disconnect between who we are at our core and the prevailing cultural tendencies in our profession. Considering the degree of compatibility between person and profession may shed useful light in understanding how an individual physician develops career burnout and opens up potential pathways to its resolution.
There are several ways in which the dominant culture of the medical profession influences career burnout among its members.
Knowing that a career in medicine is a demanding one, we take pains to select medical students and residents blessed with what we consider the right stuff. Thus, healthy doses of persistence in the face of adversity, tolerance of delayed gratification, and a love of hard work. These are all valuable qualities at one level, yet in aggregate frequently result in a denial of self and the sacrifice of those whom we love. Many of us have used our professional obligations as cover for not addressing domestic issues. Making our spouses, partners and children play second fiddle to our white coat lives can result in a painful backlash when we least expect it or are most in need of support.
Whether an individual is predisposed to burnout or not, medical school and residency training are perfect culture media for its incubation. There is endless reinforcement of the ethic of hard work, the worthiness of self-sacrifice, the merits of masking of feelings and vulnerabilities. This latter quality means that physicians’ expressions of burnout often introverted, not extroverted. The affected individual, inhibited from an admission of their struggle, tends to hide and deny their unhappiness. With our stellar work ethic we still perform well even when weary of our careers. We may be the standard bearers for doing a great job even when deeply bruised.
"After 15 years of medical practice I'm a whole lot less interesting than I used to be." Read More
Self-confidence is valuable but too high an opinion of ourselves may lead to isolation from support systems at home, at work or in our communities. Tolerating the uncertainties and ambiguities within our lives are marks of maturity, not of personal weakness. The dominant gender of our profession is one programmed is prone to deny the size and scope of a problem and slow to ask for assistance. Groomed to help others, we have difficulty asking for assistance for ourselves.
In an essay "Facing our Mistakes", published in the NEJM (1984;310:118-122), David Hilfiker said: "The medical profession simply seems to have no place for its mistakes. There is no permission to talk about errors, no way of venting emotional responses. Indeed, one would almost think that mistakes are in the same category of sins: it is permissible to talk about them only when they happen to other people". The more we physicians acknowledge our fallibility, the less career burnout we’ll see and the more effectively we’ll resolve those cases that do occur.
At about 4:35 pm on January 30th 2005, in front of an audience of 2,500 people at Hill Auditorium in Ann Arbor, Michigan, four-time Tony Award winner, Audra McDonald, had a "brain fart"... Read More
Contemporary medicine is more tightly regulated than was the case just a generation ago, and much patient care is multi-disciplinary and takes place within large healthcare organizations. Compliance and cooperation go hand-in-hand with such structures. Understanding the rewards of our inter-dependence on our families and professional colleagues and support staff, our employing organizations, and governing bodies within the profession and at the State and Federal levels is important.
As a corollary to our autonomy we often operate as independent agents even when practicing within groups or practices. When involved in teams we want to be the leader. We can be unenthusiastic about standardized regimens like care pathways, stating rather that "our" practice, "our" particular patients are "special" or "atypical" and have to be handled in an individual manner not lending itself to rote or rule. When all is going well with our professional lives, little of this may matter. But the troubled or disillusioned physician ends up feeling quite isolated and unsettled without comfortable professional relationships with colleagues that permit unburdening ourselves. In an unwillingness to acknowledge and address the problem.
"In everyone's life, at some time, our inner fire goes out. It is then burst into flame by an encounter with another human being. We should all be thankful for those people who rekindle the inner spirit." - Albert Schweitzer M.D.
My approach to alleviating career burnout follows the basic therapeutic model that we follow with our patients - immediate and short term efforts focus on symptom resolution. Simultaneously we try to understand the root cause with definitive corrective measures based on cause. A systematic, disciplined and persistent approach does work.
The primary manifestations of career burnout in physicians are feeling both emotionally and physically wrung-out, a diminished sense of self-worth often accompanied by a cynical view of our work, our practice milieu and our profession, and inefficiency in dealing with both professional and personal concerns. These generalities are colored by our particular natures and responses to stress such that some physicians are volatile and may be unpleasant with patients or colleagues while others become withdrawn and subdued, or substance abuse or inappropriate sexual behavior may emerge.
A sense of being misunderstood or unappreciated is pervasive and holds the key to symptomatic relief - the availability of an impartial advisor who helps decompress the situation by listening thoughtfully, assuring the affected physician of their value, encouraging modification of any obviously destructive behaviors and initiating a long-term solution through mitigation of root causes. Short-term solutions such as temporary reductions in clinical load if provided as a stand alone answer risks being perceived as a band-aid and an unwillingness to really listen.
The cost of sustained neglect of burnout on professional reputation and the family of the affected physician is high. Physicians experiencing burnout should seek the aid of a conscientious yet impartial advisor whose focus is their long-term professional and personal satisfaction. An advisor should understand the demands of medical practice [I don’t believe they have to be a physician], be free of institutional or practice bias [such as receiving their paycheck from the same employer as the physician], and have as their only priority the wellbeing of their physician client. Strict standards of confidentiality must be maintained. My experience is that physicians respond best to goal-directed focused approaches to their dilemma. Work with an advisor with whom you feel comfortable enough to expose your vulnerabilities. Honesty with oneself is crucial before you can be honest with another - many physicians express discontent with colleagues or practice environment while the real root cause was their choice of practice or specialty or even a medical career at all. It takes a well integrated person to turn around in their 40s or 50s and say "I should have gone for that PhD in history".
Burnout arises when the expectations and nature of the person performing the work and those of the employing organization, practice or profession are not in equilibrium in one or more of the following six measures:
Each measure should be examined in turn with each side of the equation, thus person and work environment, thoughtfully assessed. Avoid speedy conclusions - surface views and initial perspectives are commonly misleading, and in most circumstances there is more than one issue in play.
The particular nature of the problem needs to be spelled out. Thus, not, "I hate my job", but "there’s a mismatch between my value system and those of my colleagues in the practice". It should be supported by several concrete examples of where the mismatch or disconnect occurs - imagine you were trying to convince a skeptic that your point of view held water. An added value of this exercise is helping you articulate to a future employer a mature thoughtful rationale for any career move.
Target solutions should be specific and couched in positive and practical terms. If the perceived mismatch is workload, then potential solutions might be better nursing support, or reorganizing your workweek to review lab reports during the regular workday and not at 9pm. Research possible solutions.
Where relevant involve colleagues in your practice. Often, one physician may be willing to articulate their dissatisfaction with an aspect of their professional life and then find that others among their practice colleagues are of a like mind. The more solutions emerge from groups the more they will be attended to by the powers that be. Be disciplined, persistent, unwavering, and open to potential ideas that you’d never have thought of yourself. You may need to justify proposed changes to a potentially skeptical supervisor or peer whose worldview is different than yours. Thus, sketch your solutions in terms of the greatest possible good, not narrow self-interest, and acknowledge potential economic realities that may accompany any change you propose.
In some cases the solutions are readily on tap and can be accomplished without major disruption to a physician’s professional life. Where major changes are being entertained try out potential solutions if at all possible. Life as a physician administrator often seems more appealing than the reality. Finding ways to increase your administrative responsibilities to the 10, 20 or 30% level will allow you gain a feel for how much you really like administration. It has the additional merit of proving to a future employer your commitment to evolution in your career and that you had set about this in a thoughtful way. Work logically, one solution at a time in an order that is congruent with your own nature and existing responsibilities. Weigh the risk-benefits ratio of each change carefully. Decisions made out of a sense of desperation will almost inevitably prove poor ones.
At a minimum, you are considering two dimensions of change - how much and over how long. Measure the outcome of your solutions against timelines. You’ll do better by establishing criteria for degree and latency of change in advance. My use of ‘moderately firm’ is deliberate. Your aim is to be fluid and flexible about the outcome of your career examination and revitalization yet not to fall victim to forcing change for the sake of change or forcing a fit into some particular job role, both particular risks to someone in too much of a hurry. It’s equally damaging to let career frustrations drag on in perpetuity. The antithesis of career burnout is career engagement. Engagement, excitement, energy and enthusiasm is what you are after.
Read the ensuing essays on restoring and sustaining satisfaction in clinical practice and apply as many principles to your own circumstances as you can. In an ideal world, responsibility for burnout prevention and sustained professional satisfaction for physicians would lie equally between individual doctor, their employing organization or practice and the profession at the level of organizations like State Medical or specialty societies, in effect a classic three legged stool. Sadly in the real world too much of the burden falls to the responsibility of the individual themselves.
Ever sat on a three-legged stool with uneven legs? Not much fun.
Ever sat on a two-legged stool? Less fun; most of your energy goes to keeping yourself upright.
Ever sat on a one-legged stool?
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