Beyond Burnout and the Business of Medicine

This week in JAMA, Dr. Catherine Humikowski penned a wonderful article about physician burnout that I think is worth a read. Over the last few years, we’ve started to see research and personal exposés on physician burnout. We have seen in the news the tragic stories of suicides across all levels of training, from medical school to late career physicians. In response to these events, there have been more resources, usually in terms of counseling, available to trainees. There has also been a greater acknowledgement that mental health is critical to a physician’s well-being, and therefore by extension, our patients’ well-being. However, this hardly seems enough as we continue to hear what our colleagues and current trainees face.

We choose a medical career not because of a business decision, but rather we hope to make a difference in others’ lives. We are, and hope to continue to be, intrigued by the science, restored by the humanity, enlightened and entertained by our patients, challenged in every aspect, and driven to perfection. Yet we cannot escape the reality that the system is broken. Bureaucracy and administrative requirements dictate our practice, and profits have become the underlying driver of the field. 

One great point that Dr. Humikowski highlights is that, “Burnout infers insufficient energy from within, as if one’s spiritual well were too shallow, or constitution too weak.” Like most residents now, I sat through a lecture in my residency every year on burnout. The conclusion was that we need to be more resilient, that indeed the fault lies within us for these overwhelming feelings. It fails to acknowledge the systemic or institutional issues that drive physicians to burnout. Just as Dr. Humikowski discussed in her article, we too were lectured on the importance of self-care, yet we face the reality of actual institutional policies contradicting this very notion. I recall in my own residency the challenges and fear I had to request a few hours off to see a doctor or dentist for my own health. How many residents out there encounter this kind of anxiety? Do training programs have actual defined policies in place? As residents, we genuinely strive to provide the best care we can to best of our abilities, often to the detriment of our own health. Dr. Humikowski mentions, “If any industry should care for the caretaker, it’s ours. But we have not done it well.” I, and countless other physicians who leave the profession for other fields, couldn’t agree more.

There is no simple solution to physician burnout, but progress needs to be made, and large healthcare institutions that train and hire physicians have an opportunity to be at the forefront. Taking cues from other large corporations that have improved productivity and employee satisfaction, residency programs and large hospitals can offer (as Dr. Humikowski mentions) paid sick leave, child care, and maternity/paternity leave. In addition, they should also provide great and affordable health insurance coverage (I’ve trained/worked at literally the best institutions in the country, that provided the worst, most complex health insurance), a competitive 401K (to help make up for a decade of lost earnings), and student loan relief (the average physician graduates with over $190K of debt). Although capped at 80-hour work-weeks due to ACGME requirements, the reality is that many residents continue to approach nearly 100-hour work-weeks. How about offering pay commensurate to hours worked?

It’s important to acknowledge that medicine is a business. On the business side, this means more costs and lower short term profits, which is why there will be a reluctance to make substantial change. Instead, trainees and physicians will likely be offered more online modules, counseling, and seminars because talk is cheap. Real progress requires a strong will and upfront capital investments. Yet these investments will pay off in the long-term as more people choose the profession, become more productive, and opt to stay in it for as long as possible. I would anticipate with some common sense changes, burnout would be less. For substantial changes to be made, trainees and physicians need to understand how business decisions drive medicine.

At the end of the day, Dr. Humikowski says it best, “Medicine could stand to drop the attitude that we are somehow immune to the same basic physiology we have devoted our lives to understand. We must cultivate balance around us and among us, not just within us.”