Burnout is such a hot topic that one wonders whether physicians have become burned out hearing about burnout. The syndrome is hardly new; the psychologist Herbert Freudenberger coined the term “burnout” in the 1970s to describe the plight of child mental health workers in free clinics in New York City.1 (Interestingly, a wide range of professions that are intensely involved with people—including medicine, nursing, and education—appear to be particularly vulnerable to burnout.) Resulting from work-related stress, the phenomenon is characterized by emotional exhaustion, feelings of cynicism and detachment from patients (depersonalization), and a low sense of personal accomplishment. These dimensions can coexist in different degrees, rendering burnout a continuous, heterogeneous construct rather than a dichotomous one. Burnout differs from depression in that burnout exclusively involves a person’s relationship to his or her work, whereas depression is a more global experience, affecting virtually every aspect of an individual’s life. The high prevalence of physicians with symptoms of burnout (typically cited at approximately 60%), which increased during the pandemic, is extremely concerning because burnout can erode professionalism, contribute to medical errors, lead to attrition, trigger suicidal ideation, and be a contributing factor to substance abuse and relationship difficulties.
When Christina Maslach, Ph.D., published the Maslach Burnout Inventory in 1981,2 initial efforts to mitigate burnout focused mainly on the individual practitioner rather than the healthcare system. Although educating physicians about stress management, resiliency, and mindful meditation has an important mollifying role, if these are the exclusive approaches to remediating the issue, we risk sending the message that “you are the problem and you need to toughen up.”
We Are All Perfectly Fine: A Memoir of Love, Medicine and Healing chronicles the experiences of Dr. Jillian Horton, a 40-something-yr-old Canadian internist and medical educator who struggled with burnout. Dr. Horton, the recipient of the 2020 Association of Faculties of Medicine of Canada Gold Humanism Award, is currently associate chair of the Department of Internal Medicine at the University of Manitoba Max Rady College of Medicine in Winnipeg. Hers is a compelling story. An accomplished clinician, musician, and writer, she decided at a young age to become a physician largely because medical mistakes and callousness destroyed the lives of her older sister, who developed debilitating postoperative meningitis after resection of a brain tumor, and her brother, who died of undetermined cause(s) in a psychiatric hospital during the COVID-19 pandemic. Dr. Horton became resolute that she would not be one of those doctors and developed into a caring, compassionate, and highly competent medical leader. Nonetheless, she was on the verge of personal and professional collapse a few years ago, struggling with an amorphous discontent that has become medicine’s not-so-secret ailment, when she attended a 5-day retreat for burned-out physicians at Chapin Mill, a Zen center in upstate New York.
During the Chapin Mill retreat, she bonded with similarly afflicted colleagues who shared stories about secret guilt and grief. Many of them harbored a deep-rooted sense of culpability about some of their patients who had poor outcomes despite excellent care. They described feelings of marginalization and isolation, being overwhelmed by work compression, and experiencing a lack of respect and an enervating sense of lack of control over their lives. The attendees were especially troubled by administrative burdens, often exacerbated by the cumbersome and much-criticized electronic health record, and by not being allowed to work at the top of their license, functioning as cogs in a wheel rather than as valued professionals. Others grappled with a sense of moral injury when they were unable to deliver optimal care to their patients owing to a lack of critical resources, such as adequate staffing or necessary equipment.
Realizing that she was not alone, that she was one of many physicians who love their profession but have been brought to their knees by it, Dr. Horton had an epiphany that she wanted to live differently and reconfigure the parts of her psyche that were causing unnecessary pain. She began to appreciate the life-altering benefits of simple restorative practices such as mindfulness and deep breathing. She further realized, however, that mindfulness alone—although it can help us see things more clearly—is insufficient to fix the systemic and organizational problems that are driving medicine’s burnout crisis. She and her colleagues at Chapin Mill spoke often about the “toxic” culture of medicine, about the fact that their training was “an apprenticeship in the art of self-immolation,” and that physicians have the highest suicide rate of any white-collar profession.
Although Dr. Horton successfully delivers a full-hearted and powerfully intimate account of the overdetermined phenomenon of burnout, I suspect many readers would have welcomed, in addition, a deeper and more comprehensive exploration of potential solutions to the systemic and organizational root causes of this critical problem. Dr. Tait Shanafelt3,4 and others, for example, have argued that workload expectations should be realistically established, and physician well-being should be measured, tracked, and benchmarked as a strategic imperative necessary to the provision of high-quality care. Rather than being victims in a broken system, physicians should be valued partners working with institutional leadership to change the clinical environment for the better. Restoring meaning to physicians’ time commitment, facilitating supportive social interactions, and promoting the separation of work and home life may be challenging but could pay dividends in terms of physician well-being.
If burnout is not adequately addressed, the already serious shortage of physicians will become devastating. Consider that while the number of U.S. medical schools has increased dramatically during the past few decades, graduate medical education slots have not expanded commensurately. Moreover, the recent “great resignation” in our profession saw 4 yr worth of retirements in 1 yr!5 Owing to workplace disruption caused by the COVD-19 pandemic, approximately 38 million healthcare workers quit their jobs, and retirements among baby boomers doubled. Before the pandemic, the physician shortage in the United States was projected to reach 90,000 by 2025. Current predictions suggest a deficit of 122,000 physicians by 2032.
Ponder the adage that culture will eat strategy for breakfast, lunch, and dinner and realize that potential solutions must be anchored in a nurturing work culture. Moreover, the new generation of physicians will likely want to work differently than baby boomers, and this will affect the supply of fulltime equivalents. Hence, one of the healthcare system’s many challenges will be to offer scheduling patterns that align with younger physicians’ cultural imperatives.
In summary, burnout is a critical contemporary problem that has serious consequences for physicians, the healthcare system, and patients. Recently, there has been a welcome paradigm shift from viewing burnout as a sign of weakness in individual physicians to an indication of a flawed healthcare system, rooted in issues related to the clinical learning environment and organizational culture. Such a shift is necessary if we are to effectively remediate this ongoing public health crisis.
Dr. McGoldrick received no funding for this article. During the past 36 months, she received money from the Accreditation Council for Graduate Medical Education, Current Reviews in Clinical Anesthesia, and UpToDate. These financial relationships, however, are not relevant to this book review, and she does not consider them competing interests.