Collective Activism Eases Physician Burnout

Marcia Frellick

June 26, 2018

Facing patients' poverty, job loss, and living conditions as individual physicians trying to clear a path to care is a "recipe for disillusionment," says an author of a perspective article published online June 20 in the New England Journal of Medicine.

Leo Eisenstein, a fourth-year medical student at Harvard University School of Medicine in Boston, Massachusetts, says it is no wonder a physician feels defeated when an instruction not to take medicine on an empty stomach means a patient with food insecurity cannot adhere to a treatment plan or when it seems all a physician can offer is a note to a landlord saying that turning off the heat will put a patient at risk.

Burnout solutions need to start with teaching medical students, residents, and all physicians what they can do together, writes Eisenstein, who spent several years working in safety-net clinics before and during medical school.

"Each of us can advocate for our patients to be put on waiting lists for public housing. But what would happen if all doctors with homeless patients organized to demand more affordable housing?" he asks.

Collective activism is good for strategy as well as morale, he writes, making physicians feel less isolated.

Link Is Missing From the Burnout Conversation

No physician should face the social determinants of health alone, Eisenstein says, adding that this version of powerlessness around patients' environment is often left out of discussions of burnout.

John Kugler, MD, an associate professor at Stanford School of Medicine in California, told Medscape Medical News that Eisenstein "is on to something. It's a really smart take on burnout," he said, and one he had not thought much about before.

He said the helplessness described is another form of the helplessness most physicians feel at some point — whether it is generated by patients who do not appreciate how much a physician has done for them or being tied up with data entry and administrative tasks or frustration that a treatment is not working.

"I think causes of burnout are somewhat unique to each physician," he said.

He agrees with Eisenstein that there is much potential in collective activism. At Stanford, course work for students on pediatric rotations and for pediatric residents, for example, includes a trip to the state legislature to push for change, he said, adding that implementing such group advocacy in other specialties could have potential.

Eisenstein's article comes from a place of medical school optimism not always seen with physicians who are embedded in the way things are, Kugler said.

"I love that," he said. "It's inspiring and it's hopeful. We need this next generation of physicians to say 'maybe we could be doing this differently.' "

Physicians as Singular Heroes

Eisenstein says another problem is that medical students are led to believe that physicians have more power than they do.

"Despite a shift toward team-based care, the image of physicians as singular heroes, as saviors, remains embedded in medical culture," Eisenstein writes.

Kugler said that is not likely to change and argued that perhaps it shouldn't.

It is something physicians struggle with as care models change and, although physicians have others on the team to help them care for patients, they will still ultimately be responsible for the patient and need to feel that responsibility, he said.

"They don't have to be the savior or the hero, he said, but they do have to feel that they are the one responsible for helping this patient with this problem."

Richard Joseph, MD, MBA, in his senior year of residency at Brigham and Women's Hospital in Boston, told Medscape Medical News he agrees with Eisenstein that disillusionment can start in medical school.

Medical School "Breeds Competition"

He said medical school has an individual focus and "incentivizes perfectionism and breeds competition among medical students. It's not at all working to help people organize collectively as teams with shared responsibilities."

"There's a part of me that feels that medical school is selling a product that is false. It gives physicians the idea that they will have authority and be independent actors and that their decisions will carry tremendous weight for patients' health," Joseph explained.

He agrees with Eisenstein that most patients come in with the consequences of upstream factors that physicians have little control over.

"That can be extremely disheartening to see," Joseph observed. He said he came into the profession with a good grasp on the limits of physicians' power and an interest in getting involved to change what he can, but others are leaving medical school disillusioned.

"Their entire identity is so wrapped into being a doctor that if it's not the fulfilling image that they had imagined it could be, I think that really sets you up for burnout," he said.

Advocacy is one avenue physicians can pursue to motivate and energize themselves, Joseph said.

But he also warns that becoming consumed with advocacy efforts can increase burnout rather than fight it and that physicians' education should stress balancing passions while preserving self.

"You can't pour from an empty cup," he said.

Leo Eisenstein, John Kugler, and Richard Joseph have disclosed no relevant financial relationships.

NEJM. Published online June 20, 2018. Full text

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