Our health depends in part on health professionals, and there is mounting evidence that many young physicians are not thriving. A recent report in the journal Academic Medicine revealed that, compared to age-matched fellow college graduates, medical students report significantly higher rates of burnout.
Specifically, they are suffering from high rates of emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. College students choose careers in medicine because they care, because people matter to them, and because they want to make a difference. What is happening to the nearly 80,000 U.S. medical students to produce such high rates of burnout?
It is tempting to invoke the usual suspects: too many hours of study, too little contact with patients, and overwhelming anxiety concerning grades and test scores. Such stressors are compounded by exploding rates of change in medical science and technology and the general cloud of socioeconomic uncertainty hanging over the profession of medicine.
Yet the real roots of the problem go far deeper, and it is only by plumbing their full depth that we can hope to formulate an accurate diagnosis and prescribe an effective therapy. On closer inspection, burnout turns out to be a symptom of a more fundamental disorder that calls for curative—not merely symptomatic—therapy.
Nothing is more needed than nourishment for the imagination. Medical educators, learners, and those who care about the future of medicine need to understand not only the changes taking place in medicine’s external landscape but the internal transformations taking place in minds and hearts. Humanly speaking, are we enriching or impoverishing students? What alterations are we asking them, explicitly or implicitly, to make in the ways they act, think, and feel? In what ways are we bringing out the best elements in their character—courage, compassion, and wisdom—as opposed to merely exacerbating their worst impulses—envy, fear, and destructive competitiveness?
To a minority of students who care very little about such matters, such questions are likely to seem of little moment. Such students see clearly what they want to achieve—to gain admission to medical school, to graduate, to obtain a residency training position, and to take up the practice of medicine—and they do not trouble themselves about the ways in which their education is reshaping their humanity. When such students show up in class, they simply want to know what will be on the exam, and no matter how intricate or abstruse the material might be, they learn it sufficiently well to pass—and in many cases, ace—the tests.
But there are other students for whom medical school is not simply a proving ground, a gauntlet to be run, or a ticket to a well-paying and secure career. When they see a patient treated poorly, encounter a fellow student who is struggling with confusion and discouragement, or deep in a maze of tests and grades find themselves beginning to lose sight of the goals that brought them into medicine in the first place, they do not merely knuckle down and redouble their efforts. Instead they take such matters into their hearts, muse over them, and find themselves questioning whether medicine is what they really want to do with their lives.
Where can we turn to understand what goes on in the minds and hearts of highly intelligent, genuinely compassionate young adults who find themselves in a state of moral distress about the path they have chosen in life? Who or what can help them find the words to describe what they are going through, to know that they are not alone, and to locate a light at the end of the tunnel that can give them the hope and courage necessary to carry on? To understand and help such students, we need to find and apply the best resources available. One of the best guides on the matter I have ever encountered also happens to be one of the greatest novels in the English language.
The novel in question is Middlemarch. Written by Mary Ann Evans (1819-1880) who, in order to be taken seriously felt compelled to write under the pen name George Eliot, Middlemarch concerns the affairs of a fictitious British Midlands town of the same name. The title evokes not only a kind of provincial mediocrity but also a deep authorial concern with what happens to people training for the professions, echoing the opening of Dante’s Divine Comedy, “In the middle of life’s journey … ”
One of its principal characters is an idealistic if somewhat unreflective young physician, Dr. Tertius Lydgate, a character whose story provides deeper insights into burnout than any social science study I have encountered.
Lydgate is a handsome, well-born young physician with high aspirations as both a medical scientist and a servant of the needy. He comes to Middlemarch intending to found a charity hospital and to write a scientific treatise on typhus, one of the great scourges of the poor. Yet there is a problem. Over time, he abandons his ideals. He allows prevailing attitudes toward success to supplant his deeper sense of calling. He ends up investigating not typhus but gout, a rich man’s disease. Though outwardly successful, he comes to see himself as a failure. In short, he burns out because he loses his way. To paraphrase the novel, Middlemarch not only swallowed Lydgate whole. It assimilated him very comfortably.
Such changes can and do occur among contemporary medical students. Studies have documented both declining empathy and rising cynicism over the course of medical education. What happens? Having enrolled in medical school with a goal of helping people, students soon find financial considerations—including their own exploding debt—dominating their career plans.
With a growing avalanche of new knowledge and skills bearing down on them, they feel increasingly overwhelmed by what they do not know. They soon discover that, instead of expanding their capacity to make a difference in the lives of others, the rigors of medical school have constricted their field of view to their own survival.
Burnout at its deepest level is not the result of some train wreck of examinations, long call shifts, or poor clinical evaluations. It is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice. When a great ship steams across the ocean, even tiny ripples can accumulate over time, precipitating a dramatic shift in course. There are many Tertius Lydgates, male and female, inhabiting the lecture halls, laboratories, and clinics of today’s medical schools. Like latter-day Lydgates, many of them eventually find themselves expressing amazement and disgust at how far they have veered from their primary purpose.
Lydgate discovers that he has become a mouthpiece for benighted views he initially abhorred, arguing that “I must do as other men do and think what will please the world and bring in money.” Everyone needs to make compromises, but such compromises should not come at the cost of abandoning core aspirations. Quite the reverse, the primary goal should be to allow such aspirations to develop and express themselves in the challenging world of contemporary medicine. Books like Middlemarch are no panacea, but they offer precisely the imaginative nourishment so often missing from contemporary medical education, a powerful antidote to the insidious forces that produce burnout.