Get Organized to Cope With Burnout!

Burnout syndrome was a term first used not by a primary care (family) physician overwhelmed by paperwork or an emergency physician fed up with cumbersome electronic health records. In 1974, working in a private clinic, Herbert Freudenberger was the psychologist who used it. Studying factors that increased burnout risk, he emphasized personal traits (such as being excessively helpful) and the monotony of work that had become routine. He also paid attention to workers in particular settings and linked serving marginalized communities with burnout (particularly those working in private clinics, therapeutic communities, helplines, crisis intervention centers, women's clinics, gay centers and social service homes).

In recent years, burnout has become a major concern for doctors and other healthcare workers. Over time, however, its origins in clinical settings serving people needing special care have been forgotten.

As a fourth-year medical student, I have heard plenty about situations causing burnout — draining experiences such as electronic health data taking too much consultation time, extremely long working hours, feeling like an insignificant part of a vast hospital system, and excessive bureaucracy. As someone new to medicine, these frighten me. But from what I have seen both in medical school and at the public hospital where I previously worked, the private clinical setting Freudenberger described points to another underrecognized cause of burnout: caring for patients while knowing that no medicine can remedy the harm caused by their social and economic circumstances!

As medical students, we learn about both the social determinants of health and burnout, but little is said about how the former contributes to the latter. Doctors are worn down by witnessing patients' poverty and suffering, feel powerless and inadequate when unable to help patients pay their rent, and become demoralized when patients without enough food cannot regularly take medicines labeled "do not take on an empty stomach". These are only a few situations that can cause burnout.

There is another factor in burnout that is not unique to doctors, but I have seen something in medical school that makes it worse: as individuals, we believe we are more powerful than we actually are, a profoundly mistaken belief originating both within us and from those around us. Despite increasingly working in teams, medical culture still sees doctors as individual heroes and saviors. For many, doctors' white coats and medical books reflect the greatest possible individual strength and social power. But every doctor will encounter a patient with health problems caused by poverty and marginalization, and even the brightest, most outstanding doctor can feel inadequate in this situation.

Facing patients' difficult social and poor economic circumstances individually as a doctor can bring a revelation: doctors who emphasize their own power suddenly find themselves completely powerless. Instead of feeling like strong individuals, they feel alone and inadequate.

I certainly see a problem in this link between social determinants of health and burnout, but there is also a solution. If individual powerlessness is central to this syndrome, an appropriate approach involving collective action must be part of the solution. As individual doctors, we may try to get our homeless patients into public housing; but what might happen if all doctors with homeless patients came together to advocate collectively for more affordable housing?

Collective action is both strategic and therapeutic. Together, our labor and voices grow stronger, making us more strategic. When we see ourselves as part of a community pursuing a shared goal rather than as individuals alone in the examination room, our loneliness diminishes.

Some researchers have asked whether doctors' advocacy for patients is an obligation or a shared, hopeful aspiration. I think the link between burnout and patients' difficult living conditions makes this debate irrelevant. Beyond whether we are obliged to advocate for patients, collectively opposing social injustices affecting the public also benefits us by lifting our spirits, allowing us to care for both our patients and ourselves.

You may have heard it before, but I want to tell a short story: A few friends go to a river with a strong current. When they arrive, they see several people about to drown. They all immediately jump in to rescue them, but every time they save someone, they see another person has fallen in. After a while, one friend begins swimming upstream, and another, already exhausted, shouts after them, "Where are you going?" The friend replies, "I'm going to find whatever is throwing these people into the river."

The most basic lesson of this story is that prevention is more effective than treatment, but it also shows that some factors contributing to burnout stem from broader social conditions. In my view, the friend swimming upstream made the most effective decision. They saw drowning people constantly coming toward their friends and understood that an unseen force was sending them. They saw their own and their friends' endless efforts and exhaustion and sensed how close they were to burnout. To prevent this, they directed themselves and their friends toward the force throwing people into the river — the most sensible decision for both them and those drowning.

Social determinants of health and the inadequacy doctors feel when confronting them are only one part of burnout. This kind of burnout feels like trying to rescue drowning people while more people fall into danger. Being caught between two emergencies — rescuing those currently at risk and finding and confronting the unseen force endangering them... Medical students are trained to think very individual in this way and become stuck in this mindset. "What can I do?" is a question rooted in good intentions and ambition, but unfortunately it often ends in weariness and resignation. If medical schools and hospital training programs truly want to prevent burnout, they should teach us to think as a community — in other words, train us to ask "What can we do?" as the question. To prevent burnout, we should not battle these social determinants of health individually. To prevent burnout, we must become a community.

The text above is a translation of an article by Leo Eisenstein , a 4th-year Harvard Medical School student, published in the medical journal NEJM.

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