COMMENTARY

Why 'Burnout' Is the Wrong Term for Physician Suffering

Wendy Dean, MD; Austin Charles Dean; Simon G. Talbot, MD

Disclosures

July 23, 2019

Could burnout and anti-burnout initiatives championed by healthcare institutions be the healthcare equivalent of gaslighting?

"Gaslighting" refers to the act of psychologically manipulating someone to question their own sanity, in order to gain some advantage. Intentional or not, it carries significant repercussions for its targets, which in this case may be clinicians in our struggling healthcare system.

The term comes from the 1944 film Gaslight, in which a woman's husband regularly dims and brightens the gaslights in their home while he sneaks around in the attic, searching for hidden valuables. When she asks why the gaslights flicker, he insists that they have not changed intensity and that she is only imagining it. The woman's husband invalidates her perceptions and leads her to doubt her sanity.

A similar phenomenon is happening today to clinicians regarding the distress they experience as a result of the double binds imposed by the competing allegiances inherent in our healthcare system. Pro-forma surveys, used to identify burnout in other populations and adjusted for healthcare, have been widely used and revealed striking levels of distress in the medical profession. But too often, those results were not an invitation to explore more deeply and to consider whether characterizing doctors' struggles as burnout was accurate.

Doctors are finding their work challenging, but we feel that 'burnout' is a misrepresentation.

The term "burnout" suggests that doctors are not resilient enough or efficient enough—in essence, that the problem resides within the individual, who is somehow lacking. Doctors are finding their work challenging, but we feel that "burnout" is a misrepresentation.

We believe that clinicians are not burned out; instead, they are suffering moral injury. Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the healthcare context, this transgression is caused by the need to accomplish the impossible task of satisfying the patient, hospital, insurer, and ourselves all at once. Moral injury locates the source of the distress, appropriately, external to the physician and within the business framework of healthcare itself.

Healthcare systems have looked for easy fixes for physician distress, focusing on wellness (yoga, retreats, and self-care lessons), but this is misguided. Finding solutions requires that we address the problem for what it really is: a challenge inherent in the structure of the healthcare industry. Telling clinicians that they are "burned out" without acknowledging the cause of their distress is gaslighting.

Years of tough education and training have honed physician resilience. We know what it takes to be well. Eating healthy food, sleeping enough, getting exercise, and being with family are good ways to maintain physical and mental well-being. Yet, physicians are repeatedly told that the problem is our lack of resilience, and that we are frustrated and disillusioned because we do not take good enough care of ourselves.

But how does a healthy diet or a weekend retreat of yoga and meditation bolster our ability to navigate a broken healthcare system? Being a healthcare professional today entails managing the double binds that come from trying to do right by our patients, our employer, the insurer, and ourselves, at the same time.

Often, when faced with such choices, we can't choose our patients first. Each time we have to decide to put the needs of our employer, our hospital system, the patient's financial status, or insurer ahead of the needs of our patient, we sustain an insult to our guiding purpose, which is to care for our patients above all else. The accumulation of those insults amasses into moral injury.

We are being pulled in many different directions, and almost all of them are away from patient care, which is the thing we dedicated our lives to when we enrolled in medical school.

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