Elizabeth Cerceo
Camden, New Jersey, United States

 

The Exhausted Ragpicker. Jean François Raffaëlli. 1880. The Art Institute of Chicago.

The epidemic of burnout seems to afflict ever more populations as it insidiously creeps into the workplace of everyone from nurses to teachers, from medical students to seasoned clinicians, from Amazon to Apple. As physicians, we are trained to identify a condition, make a diagnosis, and prescribe a treatment. The difficulty with applying that process to burnout is that we do not fully comprehend the pathophysiology of the condition. Why is there so much burnout? And, of course, treatment development is predicated on the pathologic basis of a disease. However, we cannot wrap our arms around the root cause of burnout.

We have not had robust responses to many of the interventions we have undertaken. Wellness programs in medicine have been developed across the country, delivering sessions in mindfulness, organizing social outings or team building events, turning to the arts, and hosting yoga classes. Much effort and thought has been lavished on these well-intentioned efforts. However, the needle never seems to move that much and any clinical response is never sustained. In other words, we as the patient are not yet in remission.

What if part of the problem of burnout is the focus on our problems? We are more hyper-aware of ourselves than at any other time in history. The cultural shift has been away from civic responsibility toward the self, away from a commitment to communal values toward personal happiness.¹

This change has not just happened in medicine but is the new social phenomenon of our time. This is paired with decreasing empathy, a phenomenon of critical importance in medicine.² In other words, the focus on our issues does not necessarily bring greater happiness.

The outstanding question is whether our preoccupation with our burnout scores serves a useful purpose. Or is the process of our intense self-evaluation and concern with burnout taking us away from the source of the problem? Every conference has sessions on how to create a wellness program. Every publication has reviewed articles on the subject. Institutions all consider what event they can start to make the problem of burnout go away. But this may distract from real solutions. Our constant working and reworking of the burnout conundrum may just be another manifestation of an unhealthy self-focus.

Perhaps turning our attention to the problems of others, or even of the health system, would mitigate our preoccupation with physician dissatisfaction. Considering others is not simply a distraction but rather an acknowledgement that we are all lifted up when we mutually engage one another. Individuals who have devoted their lives to others routinely report feeling very happy, not seeing their selfless devotion as a sacrifice but something that instills joy.

Evidence on compassionate engagement with patients suggests that clinicians who are demonstrably compassionate experience less burnout. Observational data indicate that empathic physicians who consistently practice with compassion have less burnout, more resilience, and superior well-being.^3,4 Compassion has been shown to shift one’s perspective away from the self and to another. There is increasing research supporting the beneficial effect of empathy and compassion for the patients and the provider.⁵

Another consideration is that modern society has a much different conception of happiness. In ancient Greece, the word for what we call happiness was Eudaimonia. However, this is better translated as human flourishing and implies excellence in the civic sphere in concert with “areté,” or virtue. Eudaimonia was considered the highest human good we can aspire to. Philosophers from Socrates and the Stoics to Immanuel Kant believed that virtue is tied to happiness, or areté is linked to Eudaimonia. Seligman’s positive psychology marries some of these concepts, seeing Eudaimonia as a sense of meaning or purpose as well as self-discovery. As it has morphed, the modern meaning of happiness is much different than the Greek. “Happiness” is now equated with a pleasant feeling related to situational experiences whereas in the Greek it implied calm, an acceptance of one’s overall existence in all realms.

Much of the efforts against burnout are an effort to grasp at this inchoate former type of happiness and not the latter. Certainly taking care of ourselves is important and tackling the problems with our health system empowers us and helps our patients, but intense focus on our own mental state is not the answer, in part because it denies the integral importance of others and of community. That is perhaps where the answer lies, in turning the lens outward and not inward.

There are certainly institutional and system-wide issues that need to be addressed and a broken healthcare delivery system that needs to be fixed. Our discussion of this cultural perspective is not meant to minimize the things that are truly wrong with the current establishment. The individualistic models in which doctors can actually be penalized for caring for the sickest patients is the exact opposite of the ideal of a caring, compassionate physician who accepts all patients in an independent and impartial manner. A system that emphasizes the “me” aspect of medicine seeks to remove the intrinsic motivation to help others. Replacing intrinsic, humanistic motivators with extrinsic ones is fundamentally at odds with a compassionate profession.

It is time to stand back and take an honest reappraisal of our approach to the microcosm of modern medicine in the context of the macrocosm of our society. While there is not one definitive answer to the ailments of our profession, acknowledging the possibility that intense self-focus may distract us can reframe the issue. Engaging generously and openly with others and being involved in religious or social action organizations would turn the mirror less on us and more outward to others. These efforts direct our attention beyond ourselves and even those things we do every day—like caring for our patients, children, spouses, parents, friends, and family—can be done with a view of appreciation and gratitude.

 

References

1. Twenge JM, Campbell WK. The Narcissism Epidemic: Living in the Age of Entitlement. Free Press, 2009.
2. Zaki J. Perspectives: What Me Care? Scientific American Mind. 2011 Jan 1; 21 (6): 14-15. https://www.scientificamerican.com/article/what-me-care/
3. Gleichgerrcht E, Decety J. Empathy in clinical practice: How individual dispositions, gender, and experience moderate empathic concern, burnout, and emotional distress in physicians. PLoS One. 2013; 8: e61526.
4. Lamothe M, Boujut E, Zenasni F, Sultan S. To be or not to be empathic: The combined role of empathic concern and perspective taking in understanding burnout in general practice. BMC Family Pract. 2014; 15:15.
5. Trzeciak S, Roberts BW, Mazzarelli AJ. Compassionomics: Hypothesis and experimental approach. Medical Hypotheses 2017 Sept; 107:92-97.
6. https://www.washingtonpost.com/outlook/mindfulness-would-be-good-for-you-if-it-werent-all-just-hype/2017/08/24/b97d0220-76e2-11e7-9eac-d56bd5568db8_story.html?utm_term=.ba3895bfe6b8

 

---

 

ELIZABETH CERCEO, MD, FACP, FHM, is an associate professor of medicine at Cooper Medical School of Rowan University and a teaching fellow of their Academy of Master Educators. She serves as an Associate Program Director for the internal medicine residency and is the course director for the Medical Humanities at Cooper Medical School of Rowan University. She also oversees the Wellness initiatives for Graduate Medical Education and is the co-chair of Physician Engagement. As a clinical hospitalist, she is involved with education from the medical student level to faculty development, whether at the bedside, the lecture hall, or the gallery.  

 

Summer 2019  |  Sections  |  Doctors, Patients, & Diseases