The Root of Physician Burnout

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This approach is rooted in the work of the late Frederick Herzberg, a psychologist at the University of Utah. Herzberg found that two very different sorts of factors shape work fulfillment. One group of factors might be labeled dissatisfiers. These are factors extrinsic to the work itself, such as the orderliness of the work environment, the fairness of administrative policies, and compensation. If individuals feel ashamed of their workplace, unfairly treated, or undercompensated, their level of satisfaction will suffer.

As expected, reducing dissatisfiers will tend to reduce workers' level of dissatisfaction. Yet there is a limit to what can be accomplished by addressing such dissatisfiers, and merely reducing dissatisfaction does little or nothing to enhance intrinsic fulfillment. If we increase underpaid workers' compensation to a level they regard as fair, they will tend to feel less dissatisfied with their work. But further increases in compensation will not tend to improve either the sense of fulfillment they derive from their work or the quality of the work they do.

To enhance fulfillment and quality of work, it is necessary to focus on the work itself. In the case of medicine, do physicians recognize what they find most fulfilling? If they cannot see the target they are aiming for -- in this case, the aspects of their work that they find most meaningful and take most pride in -- they are unlikely to hit it. What does their best work look like? Are they making full use of their knowledge, skills, and innate abilities? Are they growing and developing as human beings? Do they feel that they are making a real difference in the lives of their patients and communities?

Burnout is not a disease. It is a symptom.

The key to combatting physician burnout is not to reduce stress, but to promote professional fulfillment. And promoting professional fulfillment is not merely a matter of reducing costs and error rates or increasing clinical efficiency. Nor is it a matter of protecting and promoting the incomes of physicians. As Herzberg reminds us, efforts to alter physician behavior through income-based incentives and disincentives are inherently demoralizing. The reason is simple: they imply that physicians care more about money than their patients. This constitutes a self-fulfilling prophecy of cynicism.

William Osler, perhaps the most admired physician in American history, understood well the recipe for demoralization and burnout: "The path is plain before you: always seek your own interests, make of a high and sacred calling a sordid business, and regard your fellow creatures as so many tools of the trade." To promote burnout among physicians, it is only necessarily to subvert their professional and personal priorities, so that they spend all their time on little things and suffer continually from a growing sense that they are neglecting the ones that really matter.

At their core, good physicians are not mere moneymakers. Good physicians are professionals. And though today we often forget it, being a professional means more than merely getting paid for what we do. Being a professional means above all professing something, declaring openly in work and life that we stand for something beyond our own narrow self-interest. The more we treat physicians as though they were self-interested money grubbers, the more we de-professionalize them. And a de-professionalized physician is inevitably a demoralized and burnt-out one.

Medicine is not a job. It is not even a career. At its heart, medicine is a calling. When it comes to physician burnout, an ounce of prevention is worth a pound of cure. We must begin early in medical education to help medical students and residents explore and connect with a sense of calling to the profession. Even late in their careers, physicians need to recall that they are summoned to something older, larger, and nobler than themselves. They must never forget that a career in medicine represents one of life's greatest opportunities to become fully human through service to others.

If we are genuinely concerned about physician burnout, we need to focus less on reducing stress and more on promoting what is best in physicians: compassion, courage, and above all, wisdom. Only by keeping what matters most at the forefront can we reap a full harvest of professional fulfillment. Burnout is not a disease. It is a symptom. To combat it, we must focus primarily on what underlies it. And here the key is not eradicating the disease but promoting professional wholeness, which flows from a full understanding of the real sources of fulfillment.

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Richard Gunderman, MD, PhD, is a contributing writer for The Atlantic. He is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University. Gunderman's most recent book is X-Ray Vision.

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