For Doctors, Delving Deeper as a Way to Avoid Burnout

1. I hate the term “burnout” and I wish physicians like Dr. Mukherjee would stop perpetuating it. It somehow places blame on the victim; it’s not the system that is beating you down that is the problem, it’s your lack of resiliency and coping skills. 2. I agree with other commenters that it’s easy to preach from your ivory tower when you have a sweet academic position and success as a writer. What about us doctors in the trenches? 3. On a personal note, I have made peace with the fact that I will never be rich. As a pediatric neurologist who does not do procedures, I’ve accepted that no one values my “brain work,” the countless hours I’ve spent obsessing over that kid with a degenerative disease I can’t diagnose. Or calming down hysterical parents. Or just listening to them. 4. I work 4 days a week, and make a salary only slightly higher than a High School principal in my district. I went to state medical school and have much less debt than others, although thanks to the aforementioned salary, is still not paid off. That is the trade off, and it works for me.

Siddhartha, I read articles like yours searching for approaches to reduce physician burnout. Perhaps some do avoid burnout by burning a little more. Neither, I nor my board at the Physicians’ Wellness Alliance, worry about those doctors. Our nonprofit's mission is to reduce physician burnout. It’s such a complex issue that we have started with a safety net for physicians in the Northwest. We’ve developed KavuMD, a teletherapy network to address issues specific to physicians. KavuMD is a helpful tool, but it’s not a cure for the problem. I would love to see a follow-up article on how individuals and organizations are tackling this issue. I urge you to highlight pioneering solutions so we may all learn and systematically apply our efforts as we would toward any serious threat to a population's health and well-being. Dan Mayhew Executive Director Physicians Wellness Alliance

Oh my goodness, are you so young as to have forgotten the lessons of the "House of God?" Your epiphany is that the golden path to happiness is to pick a NPC specialty. And your conclusion mirrors the Kool-Aid that our profs and everyone else have always offered us: I am the problem and the solution is that I just need to work harder. Thanks for talking about burn-out. It does help. Now I'm going to see some sick people.

For doctors in primary care the solution is a direct primary care model with no insurance. It allows the doctor to practice medicine as it was meant to be, without the insanity of modern medical insurance and modern medical coding and EMR, to spend adequate time with patients and focus well on their issues, and is financially sustainable to boot if done right.

Conclusion to previous comment. I am blessed to be a doctor and patients would tell you they feel the same about me. Like the author, I attended Harvard Med School and few people with those credentials pursue primary care. I have had a rewarding career because it is easy for me to see the meaning and incredible impact we can have own people's lives. But I also make a lot more money than average in the country for primary care and that has helped delay burnout. I am in a doctor run multi specialty private practice and affiliated with a large Health system but not owned by them. I have control over my office hours and I am part of the leadership of our group. Having some control over your destiny is also part of satisfaction and many of us have ceded this to bureaucrats. We are lucky to be doctors in the US and are paid better than anywhere else. But if you want primary care doctors burnout less quickly, pay us like specialists. It is a sacred honor to be a physician and there is plenty of meaning in this profession but you may have to stop for a minute to realize it!

There are a lot of systems issues in medicine that need to be addressed and fixed. At the same time, I quite understand the drive of this article. A fact about my field - geriatric medicine -- that is not well-known is that we consistently rate highly in satisfaction compared to other specialities/ fields. It's unusual because geriatric med is neither high-paying (relatively) nor glamorous but I derive a lot of satisfaction from helping elderly people maximize their function, retain their quality of life to the end as much as possible, etc. I've also had the honor of learning history from my patients: as a fellow, my 101-yr. old pediatrician patient with all his marbles intact would tell me stories about the times when there were no antibiotics. There is a lot of meaning to the work and it is quite appreciated by families, especially by MD colleagues who understand our role better when we take care of them or their parents. I also remember a lesson from my mentors when I was depressed about the state of medicine as a resident. They reminded me to notice and celebrate the "small" victories and successes e.g. helping a patient understand their illness better, comforting a grieving relative, getting a patient with late-stage, non-verbal patient with Alzheimer's to trust you enough to let you examine them.

Non-surgeon physicians are now machines to translate patients' words into billing codes.

Let’s not forget the PAs and NPs who practice alongside MDs. Except in the surgical theater, we’re expected to see the same acuity of patients; complete the same EMR charts (which in some states bill under the name of the attending MD—who may/may not perfunctorily sign off on reports), and; work similar hours. We’re paid a fraction of the MD salary, and many often less than RN’s. Sadly, national/state RN and MD organizations do not always lobby for increased NP or PA autonomy or improved compensation. I know millions of patients and families appreciate the quality care we deliver. Before I became an advanced practice nurse I predicted being tired, and I could even imagine feeling burned out and overwhelmed. However, I didn’t anticipate the professional isolation and the strains it can cause in a care team.

Amazing how relevant Frankl's book remains. It made a lasting impact on me as well; lack of resilience and motivation happens in my field (music) too.

Matches my exact path, from burnout, to leaving the internist grind, to mastery and autonomy in a non-clinical niche field - and happiness - to the pebble. My son is applying to medical school now and he’s read this pitch-perfect piece. I look forward to discussing it with him. And I vow to insist he read it (lest I demand to read it to him) at least annually until I no longer draw breath

I began my practice working only 3 days a week. After 25 years this is still the norm. My husband (dentist) and I organized our work days to raise our 2 daughters ourselves (no nannies). Likewise we adjusted our lifestyles and goals to live within our means (which were still very generous). I do not bring home any work and I take 10 weeks off a year to travel (very fortunate to have a great locum who covers my patients when I am out of office). And next year I am celebrating my 30 year graduation by traveling to the Galapagos with my anatomy partner I met the first day of med school where we shared a cadaver. My advice? Begin as you mean to go on.

Thanks for explaining an important and worsening societal problem. As I see it we are being pushed toward other less satisfying and more stressful goals than practicing medicine. Included: the need to practice and chart defensively (the malpractice system in U.S. is way out of line with the rest of the world, but that's a topic for another day); the need to chart to optimize billing (which is ever-changing) rather than for the benefit of communication amongst health care team members; the need to satisfy institutional goals that are not aligned with patient care needs (too many to list). Things like weekends and call (currently 1 in 5) are not so bad, since that's what I signed up for. But others have capped hours (residents and nurses, support staff ) and don't seem to understand that it is not appropriate to call at 1am for non critical lab results that were drawn at 11 am the day before. It's little things like that that add up. Oh and do not even try to politely and respectfully correct or teach a non physician who is not doing their job, microaggression, safe spaces, and political correctness now rule the day. Just convince yourself it's not my problem, it's the hospital's, and hope they will figure it out before someone gets really hurt. When the CMO isn't on the same tier as the CEO, patient care will continue to suffer.

Well written. I love the 'Delve Deeper' approach as it has worked like a charm for me. Over the past few years, there have a growing number of physicians (now thousands) that volunteer within the organization, Walk with a Doc. It's simple. These doctors are ditching their white coat and showing up in parks around the world to talk, walk, laugh, and connect with their communities. They say the hour of time they donate is reminding why they went into medicine. As Kathy Barker shared, the bigger picture is refreshing and rejuvinating.

I wonder why single payer health care wasn't mentioned as something that could bring control and pleasure and dignity back to a medical practitioner (as well as to clients)? There are a few organizations out there such as Physicians for Social Responsibility that can bring a bigger picture to your work.

I'm a geriatrician. Most of what we do is cognitive not procedural and our practices' financial health are nearly entirely at the whim of Medicare, a source of much stress. We are not rich and most med students do not want to be us. And yet most of us are pretty happy. Why? We chose this. We love the complexity, the weird family dynamics, the force of narrative in older people's lives, and focusing on what really matters. Does the EHR make us crazy? Sure. Can I find 2 bullets for 9 systems to get to comprehensive? Sure. Am I careful to document that this 94 y.o. declines tobacco cessation counseling. Sure. But mostly what I do is listen. A recent new patient told me that "you're an old fashioned doctor." I was rather appalled but she continued by explaining, "you talk to me. My last doctor talked to the computer." Of course by not charting during our visit, I am adding to my potential burnout by ensuring that I have to do work at home. But I do think that the relationships we build and the meaning we receive from really making a difference for our (often very frail) patients helps to inoculate us. While most of us are not investigators, we go deep by investing in our patients' lives.

I was literally thinking today about how I appreciated this creative writing class I took at UCSF when I worked at the medical student well-being office. I went on to get a low residency MFA. My day job is as a psychiatrist. I wondered why they didn't mention creativity, humanity and the arts in this article. I feel like coming up through med school there is always this lip service to the 'art and science' of medicine, but somehow along the way the art part got dropped. Was it ever there? Increasingly there is more and more pressure to drive away all our other passions and hobbies, so that creativity has been so squelched in medical people. What a shame. When I took this class at UCSF with the student (I was on the staff), I was amazed at some of their fictional stories and poems. And now that I study playwriting, I've found something that I love that makes my job as a psychiatrist better. Why can't we foster and nurture that in the medical profession?

I couldn't agree more with the physicians commenting here about the creeping loss of autonomy in medicine. I left my practice after almost 30 years because I no longer had control over my own schedule, my own documentation, and my own medical decisions. I increasingly felt like a factory worker manning a conveyor belt of patients and the corner office was turning up the speed of the conveyor belt, with little regard for the varied complexities and needs of each patient. I was taught in medical school that the majority of diagnostic work and relationship building occurs during the Q and A with patients. When medical providers don't have time to listen and patients don't feel listened to, unnecessary or incorrect tests are run and there is dissatisfaction all around. If the conveyor belt in a factory is moving too fast and a factory worker makes a mistake, maybe there will be loss of money or the company gets sued. If the conveyor belt of patients is set too fast, mistakes are bound to happen, but in this case the stakes are totally different. Patients may suffer or die. And who would get sued? The physician working the line, not the MBA in the corner office. I am a physician who would rather not practice than be forced to do a horrible job. Seeing my patients was the best part of my day and I will miss them, but I weighed risks vs. benefits and decided that the risks of remaining in practice were too great.

I'm an allergist in solo private practice for 25 years. I work 3 days/week, I have no EMR (for which I am now penalized but I don't care), I have good billers who deal with that, good nurses who have been with me many years, and long term relationships with my patients in the allergy shot clinic. Rewarding medicine can be practiced in many ways.

I find Mukherjee’s description and analysis of burnout lacking and hardly relevant. Harvard trained physicians with elite training in genetics and stem cell technology, brandish their success in converting their passions to research and academic activities unavailable to the usual practicing physician. Burnout lives in those of us who neither graduated from elite universities offering a menu of opportunities, like the author (who doesn’t need to record patient data in an electronic record, likely because some resident or scribe performs such lower order work), nor found pathways to exercise our passions in teaching and research. Some of us did find another way, through resourcefulness and creativity, by attaining additional degrees and leadership skills, to work on the transformation of healthcare. Improving the satisfaction of those of us who still touch patients, against the landscape of value-based payment changing salaries and work flows, is the work of physicians and other clinicians assuming the mantle of leadership. Dr. Mukherjee, you are too far up the food chain to begin to understand the dilemma of burnout. In fact, I am willing to bet the salaries of you and your colleagues far outstrip the average clinician’s. Congratulations on your achievement of mastery, autonomy and independence, from those of us who find that philosophical ideal irrelevant.

As a current ER resident I shared the alienation at the last lines of other commenters... the solution to being overworked is more work? I suspect that the research portion of the writers hours are not pressured in the way of an ED clinician, internist or intensivist’s... same for the super specialized clinic hours... and yet someone needs to work in the ED and on the floor and in the ICU.

So , yet another article which preaches resilience when the real question is why should we need to gird ourselves for war and trauma (work these days feels that way, it is a battlefield out there) when the focus should be more on preventing it? What happens to those who are purely interested in clinical medicine? The fortunate few you are at the top of their game bail out into leadership roles, nonclinical roles and take care of themselves. What happens to the rest?

It is almost impossible to simply practice medicine. The demands of insurance coding, recertification (beyond almost any other profession), electronic health record intrusions, and emotional drains and expectations in dealing with patients will take a toll. It is hard to see any simple way around these embedded concerns. Then you can add in the debt load (average just under $200K before you factor in interest during repayment), and income spreads (4-5 fold between specialties) that make planning for the future very difficult. Training demands include undergraduate and medical school (usually 7-8 years) often followed by another 3-8 years of residency and fellowship. I was left medicine at 60, with little or no debt from med school (graduated 1972) and a career that spanned academics and private practice. I avoided the morass of electronic medical records. The coming changes were apparent to me--but I was still the beneficiary of a lot of luck. It was not medicine itself that made me leave (not so prematurely, though), but all the escalating bureaucratic demands. The scene is much more difficult for recent medical graduates. I hope we can figure all this out, but do not expect much from legislators, given the burdens our over-priced medical system places on society. NYU has started a program to cover med school tuition, which will help a few, although one can argue that perhaps 2-3 years of public service should be expected (not simply military service).

This is a nice reflection on a very real and dynamic reality. Burnout is seemingly more common among my colleagues. We often talk about other career tracks and opportunities that typically die out due to inertia and faded dreams. To self assess my own response I feel that I have retreated from the practice of medicine: I do the minimum for my employer and no longer eagerly volunteer for corporate charity in terms of programmatic development in the hospital or clinic. I really don't understand why physicians continue to agree to taking unpaid 24/7 call. Institutional loyalty is a fallacy and self preservation will allow me to continue to care for my patients (the real joy). Our system response: "come to grand rounds on mindfulness" My response: "no, i will work at my desk through lunch to edit my transcriptions so that I can leave for home at attend to what really matters"

1. Only work 3 or at most 4 days a week. 2. Never work post call 3. If u feel u work in an antagonistic work place where you are essentially bullied ( yes ladies and gentlemen plenty of bullies of both sexes abound) get another job if possible. 4. Get out of debt asap 5. Don't fall for the trap of working yourself to death at the beginning of your career to build your nest egg. It will slowly come. 6. Now if only I had taken all the above advice. 7. Make sure u have some real friends.

Am I to assume from this conclusion that those of us who completed residencies and fellowships and then committed ourselves primarily to patient care did not “burn a little more”? I guess it is about how you look at yourself.

Excellent thought provoking article. As a psychologist, I'm professionally aware that anyone in medicine and related fields these days is highly subject to burnout, including psychologists, nurses, social workers, every kind of MD and so many others. The search for meaning and the intrinsic value of what almost all of us entered our professions for has been steadily carved away over time. And it's accelerating as mergers and profit motives with CEOs raking in so much money it's obscene leaves far less for care and salaries for dedicated professionals. Most of whom are overworked, spending too much time away from their families, in order to do idiotic administrative garbage that has nothing to do with medicine or psychology. and often to avoid lawsuits that corporate lawyers perseverate about. It has been shown over and over and over again one of the most "curative" factors in medicine or mental health care is the RELATIONSHIP between a doctor and their patient. That is one of the most robust findings in medicine and psychology and continues to be true. People heal faster, get sick less often, care for themselves more and feel better when they are connected with their professional caregivers. In the long run, until the empty suits understand relationship is VITAL to healthcare, there will be more and more good people that leave medicine and psychology. Just when we need more! Thank you for writing this excellent article.

An insightful summary of the statistical extent of burnout and a framework for understanding its causes. But other than smug self-congratulation, I’m not sure about the overarching purpose here. His colleague’s frustration at not touching a patient is solved by careers that involve little or no physical contact with patients? I don’t begrudge anyone that finds meaning, mastery and autonomy in their career, but discussing the accomplishments of four Harvard graduates in this context is either naive or disingenuous. And though common in discussions of burnout I think ‘resilience’ per se has fairly little to do with the problem. Those that work hard enough and perform well enough to be admitted to medical school have displayed a good deal of resilience already. Resilience is a characteristic of the individual. Purpose and mastery are certainly related to individual traits, but autonomy is not. If any individual traits are causative where burnout is concerned, it is our pursuit of (over) achievement and of a career that provides meaning. Even among college graduates the latter is something of a luxury, though unsurprising in those that feel a calling to their chosen career. What we need are more practitioners, more worker bees. The world of academic medicine and medical research, while of immense value, is rife with its own problems as are lay reporting and science denialism. I would encourage Dr Mukherjee to write about topics he has more experience of or to delve deeper.

Physician burnout is a hot topic these days, within the profession and in the lay press. Everyone acknowledges the problem which is large and growing. This piece is yet another example of the 'teach resilience' movement, and that's the problem. The author notes in passing that Electronic Medical Records (EMR) have streamlined work and 'ensured patient safety.' They haven't. They have dramatically increased physician clerical work and taken doctors away from their patients. They are great for billing. They are designed to 'generate a charge' for every physician act - an artefact of our dysfunctional and immoral healthcare finance system. Doctors aren't in charge of medicine any more. We work for corporate entities. The administrators tell us what to do. We can't order the tests we want or do the procedures we think our patients should have. The insurance companies are in charge of this. That medication you think the patient needs? Did you get the prior authorization? Should I fill out another form? Do I have to make a phone call for 'peer authorization?" Physician burnout is learned helplessness. It's abuse. The programs aimed at teaching resilience, at mindfulness, are great as far as they go, but they ultimately remind me of Rape and Abuse Crisis Centers. Wonderful institutions as far as they go, but maybe we should figure out how to have less rape.

I can only speak for myself (an outpatient internist), that I've avoided burnout by working a little less, pushing back a little to have some time with my patients, getting very minimally involved in research (and would love to do more), reading a lot (in medicine and outside of it), having a hobby, and being lucky enough to have a loving family and to find a clinic with great colleagues and a positive attitude. I agree with both the author and with the comments so far. I've been sad to see some of the best doctors and one nurse practitioner (with over 40 years of clinical experience - a precious clinician) burn out because of the problems described here. I agree completely that absurd documentation requirements and undervaluing of primary care and other non-procedural specialties are destructive to integrity and to doctors' and nurses' love of their professions. I would welcome the opportunity to solve those problems, if it didn't force me to give up those things that have sustained me. They are political problems at their basis, and as such are outside of most doctors' skill set. I think this is one reason doctors tend to roll over when told to do things they don't want to do. They think there is nothing they can do to fight it, and it is a self-fulfilling prophecy.

Most of us in the profession cannot devote a significant amount of time to research activities and many of us would not find satisfaction in that anyway. Consider how much research is done mainly for academic advancement rather than meaningful advancement of medical knowledge. Of the three factors leading to professional satisfaction, purpose, mastery, and autonomy, I think the loss of autonomy is the most significant. Studies have shown this is more important to physicians even than loss of income. The corporatization of medicine has led to MBA suits who have never cared for a patient running the show. They know and care for only the bottom line and how to increase it. A colleague of mine, now retired after 40 years of practice. relayed a story to me about a corporate suit who was telling him he needed to compose his clinic notes differently. Before becoming a corporate suit, she had been a lab tech. I had a similar experience with my clinic notes while working for a large health system. I was told that I was not using the proper "verbiage" in my notes. When I pointed out that verbiage meant excess wordiness they had no reply. I told them that if they didn't like my notes they could fire me. Given the acute shotage in my specialty they didn't take me up on it. The concerns of the health system in both instances was billing, not the effective communication of information to other physicians who might be inclined to read my notes. It must change.

The author seems to suggest that physicians who cannot find a solution to burnout work less than physicians who find fulfillment in niche research endeavors. I applaud the work of researchers and am grateful for their dedication to advancing medical knowledge, but if all of us sought fulfillment in research, who would be present for the patients? As a pediatric intensivist, I do struggle with burnout for many of the reasons listed in this article; however, I could not find purpose at a bench. I find it in my interactions with children and their families, in being an active participant in acute life-threatening emergencies, and guiding patients and families through end-of-life decision making. I do not have a cure for the plague of burnout, but when someone who does not spend as much time at the bedside suggests that those of us on the front lines of patient care haven’t dodged it because we don’t work as hard, that only contributes to the problem.

Who wants to be on call? Who wants to work weekends? No one. Work life balance for all. Unrealistic expectations fuel burn out.

An idea not explored in this article is whether veering in the directions suggested by the author to avoid burnout actually helps prevent it, or whether those individuals who have some innate resilience are thus drawn to those areas. I'm not a doctor or a researcher, but separating out cause and effect is a fundamental aspect of all research, right?

Great article and important article. I am a family physician who started a mindfulness program at my hospital to try and address burn-out. The 'program' is simply offering 1 mindfulness session a month (with a trained mindfulness practitioner)- a drop in the bucket- but at least a drop in the right direction. I wasn't necessarily reassured that the author's examples of those physicians who maneuvered past burn-out did so, by and large, by practicing in a field of medicine with little patient contact. We seem to forget we have free will- that is, primary physicians on the front line are treated as if they work for another country- or some entity with total power over much of their conduct- as if this entity, usually with relatively little medical knowledge, is nonetheless all knowing and justified in batting around one inefficient intrusion after another. I get it. I get it. It's economics. But that's a shame. I've noticed other government bodies, like the EPA, are sued when they don't do their job. I'm still trying to figure out why we bend over and let the medical complex off the hook.

The vast majority of still-practicing physicians do not have the opportunity to carve out niches of focused passion and meaning. They are now employed by profit-driven corporations who dictate the terms of their paychecks. Dr. Mukherjee describes the exceptions that prove the lamentable rule.