Doctors don't burn out
They undergo something *even worse* (or so they say). Also: a new essay on knowingness!
I have a new essay on knowingness, the posture of already-knowing that pervades our culture (a topic I just can’t quit), in Psyche, which is the sister publication of Aeon, the extremely smart British online magazine. Here’s a passage from the essay, “Our Big Problem Is not Misinformation; It’s Knowingness”:
In 21st-century culture, knowingness is rampant. You see it in the conspiracy theorist who dismisses contrary evidence as a ‘false flag’ and in the podcaster for whom ‘late capitalism’ explains all social woes. It’s the ideologue who knows the media has a liberal bias – or, alternatively, a corporate one. It’s the above-it-all political centrist, confident that the truth is necessarily found between the extremes of ‘both sides’. It’s the former US president Donald Trump, who claimed, over and over, that ‘everybody knows’ things that were, in fact, unknown, unproven or untrue.... Knowingness is why present-day culture wars are so boring. No one is trying to find out anything. There is no common agreement about the facts, and yet everyone acts as if all matters of fact are already settled.
I have been reading Aeon for a long time and identified it early in my writing career as a goal publication. (Psyche is newer, and it’s where shorter essays usually go, whether or not they are on psychology.) And here we are!
Note that Aeon/Psyche does not have a paywall. You can click, read, share, and enjoy this essay with utter extravagance. And I hope you will. I think knowingness is a crucial concept for understanding our culture and the conflicts therein. It’s a heck of a lot better than “gaslighting,” for crying out loud.
A friend pointed out recently that Jonathan Lear — godfather of the concept — sees Oedipus using knowingness as a defense against his fear. That’s a very good point that I maybe ought to have explored. I hope someone can build on what I’ve written and say more on that point.
I have two more short essays coming out soon in familiar venues; I’ll say more about those pieces in a couple weeks.
For now, I want to talk about physician burnout — or possibly, super-burnout.
In a New York Times opinion essay last month, Eric Reinhart, a psychiatrist who also has a Ph.D. in anthropology, wrote about the demoralization of the medical profession and the need for serious reform of physicians’ working conditions:
Doctors have long diagnosed many of our sickest patients with “demoralization syndrome,” a condition commonly associated with terminal illness that’s characterized by a sense of helplessness and loss of purpose. American physicians are now increasingly suffering from a similar condition, except our demoralization is not a reaction to a medical condition, but rather to the diseased systems for which we work.
Along the way, he questions what has become the go-to term for describing physicians’ problems at work:
To try to explain this phenomenon, many people have leaned on a term from pop psychology for the consequences of overwork: burnout. Nearly two-thirds of physicians report they are experiencing its symptoms.
But the burnout rhetoric misses the larger issue in this case: What’s burning out health care workers is less the grueling conditions we practice under, and more our dwindling faith in the systems for which we work. What has been identified as occupational burnout is a symptom of a deeper collapse. We are witnessing the slow death of American medical ideology.
It's a small point in Reinhart’s piece, but I think dismissing burnout in favor of demoralization is a mistake, in light of both the research on burnout and Reinhart’s strategic goals to organize clinicians so they can “call for a fundamental reorganization of our medical system.” It's true, as Reinhart suggests, that there is no precision in the public discussion of burnout, and so much of that discussion places the onus for solving it onto workers themselves. But that's no reason to dismiss the term; it's a reason, rather, to bring more of the research on burnout into the mainstream public discussion.
The situation Reinhart describes — not just degraded working conditions but a ruined ideology — is in line with how I define burnout in The End of Burnout: as the experience of being stretched between your ideals for work and the reality of your job. The large numbers of physicians who score high on standard burnout measures might be doing so for exactly the reasons Reinhart says they're demoralized. When I read about demoralization among physicians, I see descriptions of burnout — at least, of burnout properly understood. (Here’s a 2021 New Republic piece I wrote on that point; also, chapter one of my book is titled, “Everyone Is Burned Out, But No One Knows What That Means.”)
Other physicians have made similar claims that members of their profession suffer from something beyond burnout. In 2018, Simon Talbot and Wendy Dean argued that doctors were going through moral injury, a concept borrowed from studies of the psychological damage that combat can cause soldiers. They say “the concept of burnout resonates poorly with physicians.” But when you look at what the authors say is going on in their profession, it sounds a lot like burnout. Doctors, they write, have high ideals:
Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges.
But the actual conditions of their work don’t match up with those ideals:
In an increasingly business-oriented and profit-driven health care environment, physicians must consider a multitude of factors other than their patients’ best interests when deciding on treatment. Financial considerations … lead to conflicts of interest. Electronic health records … overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and over-react to results — at times actively harming patients to avoid lawsuits.
That is the definition of burnout! The phenomenon so prevalent because, for the past fifty years, professional ideals in the U.S. and many other countries have risen while working conditions have, in important ways, gotten worse. Burnout is a spectrum of experience, but the worst sufferers become constantly exhausted and embittered and fall into despair.
Someone might (unsympathetically) say that some doctors reach for “moral injury” or “demoralization,” rather than “burnout,” in order to raise themselves above other medical workers. The terms could be a means to shore up the distinction between doctors and other people who wear scrubs — and who have been permitted, in recent years, to perform tasks previously reserved for MDs. If that’s the case, then using the terms aligns with the century-long quest for "elite status" Reinhart sees as contributing to the current (bad) system.
Since all sorts of professionals — not to mention patients — are suffering within that system, reform-minded doctors have good reason to find common cause with them. A focus on burnout rather than demoralization or moral injury can help promote solidarity across medical staff. The literature on burnout among nurses, techs, and administrative staff is vast, and these workers are all suffering within the same system doctors are. Burnout is already in these workers' vocabulary, even if they might not define it the way I would. Because burnout is widespread, cutting across job types within medicine and other sectors, it has great potential to be an experience around which workers can organize. We are all burnouts-in-the-making. It will take solidarity across job descriptions to demand change to the systems in which we work.
The Times published a very good collection of letters in response to Reinhart’s essay. (That is a free link.) They’re worth a read. My favorites were the last two. You’ll see why.