Physician burnout challenges our assumptions

I probably set a record for the earliest a physician ever burned out: less than a year after earning my MD. Some may not call it burnout; it could just as well be called “internship.” I call it burnout because beyond the exhaustion and can’t-take-it-anymore, there was a gnawing sense that something fundamental was missing — something that no amount of time would fix.

Over the next year or so, the exhaustion and feeling of incompetence started to subside (the latter more than the former), and I began to adapt to the flow of health care. Then I asked myself a question: “Do I really want to adapt to this?”

“No, I don’t,” came the answer.

I thought about it more. What didn’t I want to adapt to? What exactly was the problem I was facing? I contemplated this for some time as the answer slowly clarified itself and burnout made its exit.

Medical science is one of the few fields that dares to try and define the human being. As best as it can, medical science nobly approximates the human being within a model of anatomy and physiology, the foundation on which the rest of medicine is developed and practiced. That model — the one Henry Gray studied and Frank Netter immortalized in his sketches — is built on some very bold assumptions.

They’re not just any ol’ assumptions. They’re philosophical assumptions. As with every science, medical science is born from the reasoning of philosophy. Let’s have a closer look at the most basic of all its assumptions.

Assumption: The human being is primarily a physical structure.

Almost every area of medical science focuses exclusively on the physical body. Psychiatry can be a notable exception, although it too often equates human experience with physical neurotransmitters. (The two are certainly associated but there is a large explanatory chasm between the presence of a neurotransmitter and the smell of grandma’s apple pie.)

Are we actually physical structures or is physicality simply one of the ways the human nervous system interprets the world? This is a profound question and one that is supremely relevant to discovering mechanisms of experiencing wellbeing, healing, and cure. Medical science answers the question by saying “I don’t know, but either way, working with a physical structure is easier. What’s the alternative?”

That’s a fair answer, but it can’t be our final answer. You don’t need to be a philosopher to recognize that every experience we have is first and foremost just that: an experience. It may be an experience of something physical, mental, good, bad, sublime, or grotesque — but fundamentally, it is an experience.

If we choose to focus primarily on physical experiences, we can. And we can then explain everything else in those terms. That’s what medical science does. This is the default approach of almost all our education — grade school through medical school. If we choose to focus primarily on mental experiences, we can do that too, although it may require a little practice since we’ve been taught to do it the other way around. With practice, we could focus on mental experiences and explain everything else in those terms.

The problem we run into with the default approach is that at some point, the model breaks down, and it ain’t pretty when it does. As mentioned above, the physical model explains the smell of grandma’s apple pie baking in the oven in terms of action potentials and neurotransmitters. Yet there’s nothing about these that even closely resemble the smell of apple pie. This is an obvious, glaring discrepancy that we have no choice but to ignore if we want to stick with the current model. It would be much more parsimonious to say that all experience is mental, including that of physical things, a physical brain, and a physical body, which are simply varieties of experiences. Where is that razor of William Occam’s when you need it?

The scientific evidence supports the latter view as much as it supports the default view, because science does not comment on the quality of its assumptions, only on what it derives from those assumptions. Yet the two are inextricably linked. Better, more accurate assumptions yield truer, more powerful science, and the potential for a better experience across the board, including in health care. The problem is that the latter view sounds so counterintuitive against the backdrop of the education we have cemented over decades.

If this were all merely a question of academic fancy, perhaps we could ignore it. Perhaps we could bat it around for a bit and then throw it into medicine’s basket of hard nuts to crack. But consider that the solutions to diseases like cancer, autoimmune disease, and mental illness may remain at bay if the model we are using isn’t the best one. Consider further that the epidemic of burnout we’re seeing is sustained by the perspective of the human being as a machine — an artifact of the default view. Calls for participatory medicine, clinician wellness, improving rapport, and valuing the person behind the patient and professional will remain weak-throated as long as they’re competing with an unexamined, default scientific view.

These insights helped this struggling intern to see what health care could be and how. After surviving internship, I decided in my second year to not adapt to the flow of health care. I decided to rather see how I could add my perspective. That was almost a decade ago. Since then, I have seen that much of the suffering that happens in health care to both patients and professionals is preventable, if only we judiciously apply Occam’s razor.

Happily, we’re already in the early stages of its application. All the buzz about burnout and wellness is a sign that we are getting close to coming face to face with the most basic of medical science’s assumptions. When it happens, we will have a difficult choice to make: Stay with the familiar and comfortable, or choose what’s counterintuitive yet promising. Of course, we won’t have to make the choice in a single moment, but the more we contemplate it today, the easier and more clear the choice will be tomorrow.

Anoop Kumar is an emergency physician. He is the creator of How to Cure Burnout and Feel Good Again: An Online Immersion for Healthcare Professionals and blogs at his self-titled site, Anoop Kumar, MD.

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