It is no surprise that burnout is surging along with this latest pandemic wave. Exhaustion—both physical and moral—is the ashen heart of burnout. Even as the flood of patients recedes in some areas, health care operations are hardly back to normal as many systems struggle with staffing shortages. In the hospital where I work, nurses have carried up to double their normal patient load, while the remaining phlebotomists on staff hustle to draw “morning” labs by 2 p.m., and patients are asked to self-administer their inhalers to free up respiratory therapists for other tasks. As we struggle to adapt, more and more health care professionals consider leaving their jobs, exacerbating shortages.
In response, employers and institutions are rushing to address burnout. We receive regular emails on “wellness resources” and “self-care.” We are encouraged to meditate, exercise, eat well, practice yoga, and find that elusive work-life balance. “Physician, heal thyself,” the subtext reads. I do not doubt the importance of self-care, but I find the aphorism about as effective as caring for my patients by saying, “Patient, heal thyself.”
Though burnout can be isolating, it does not occur in isolation. The three key features of burnout—exhaustion, cynicism, and feelings of inefficacy—are the outward manifestations. Self-care may help us mitigate these symptoms of burnout, but addressing the root cause requires identifying and fixing the underlying systemic problems. Even before the current pandemic, growing attention was focused on clinician distress. Many causes of burnout have been identified, but the taproot at the center of this network is a commercial health care framework that profits from disease.
The financial incentives of this framework pervert every level of the health care apparatus from the interaction of each patient and clinician to the highest levels of administration. The financial transaction occurs between the customer (insurance payers) and the seller (health care corporations), each motivated by market pressures to maximize their own slice of the financial pie. Incidental in this transaction are the patient and clinician, who are each left to navigate increasingly byzantine bureaucracies to achieve the care nominally at the center of this relationship.
The moral injuries that result from this arrangement come in many forms—watching my uninsured patient move inexorably toward amputation because he couldn’t afford the $100 fee to see a podiatrist, arguing in vain on a “peer-to-peer” call for rehabilitation for my patient after she suffered a stroke, admitting a patient with yet another episode of diabetic ketoacidosis because she can’t afford her medicines. We all have these stories. They are the daily detritus of an organism that consumes disease and spits out profits for those who need them least. The caring relationships with patients, the collaborations with dedicated colleagues, the lifelong learning, the nurturing of the health of our communities—in short, the reasons why we went into medicine in the first place—must be snatched from the jaws of productivity goals and the computers deputized to track them.
We essentially work in a surveillance state, constantly interrupted by administrative tasks that contribute little to the health of our patients or communities and distract us from the cognitive and physical work of caring for them. A huge part of our day is consumed with trying—and often failing—to figure out how to pay for the care our patients need. It seems we spend as much time documenting diseases as we do treating them. Despite our best intentions, the actual care we manage to achieve in this context is often substandard, especially for uninsured or underinsured patients, who languish in a separate and unequal system of restricted access to care. Even our patients fortunate enough to carry “good” insurance are often unable to access essential services as the gatekeepers who hold the purse strings demand increasingly arcane justification. How can we who took an oath to heal not be incensed by the injustice and inhumanity?
A compelling financial case has been made for addressing burnout, which results in staff turnover, reduced productivity, and compromised patient safety. Health care organizations feel these pressures and respond by focusing on the individual, which threatens to blame the canary for the toxic air in the mine and adds to onerous administrative burdens. Nor is the answer as simple as “work us less, pay us more,” as a colleague once suggested. Restorative time away from work is essential but insufficient if we return to a morally bankrupt workplace built around profitable sickness.
We must move beyond individual responses, beyond resilience and grit, beyond self-care, to recenter our health care system around the health and well-being of our patients while grounding our practice within the collective thriving of the communities in which we live and work. When patients are more than their diseases, and we are more than productivity machines, then we can rekindle the joy and fulfillment that comes from the deep privilege of entering the life of another at their most vulnerable “to cure sometimes, to relieve often, to comfort always.” Only then can the adjuvants of practicing self-care and building resilience stem the rising tide of burnout.
Transformative change is imperative, but hardly inevitable. Innovations such as value-based payment reform inspire hope for increased alignment between financial and ethical concerns in medicine, but have yet to be widely adopted and too often rely on easily-measured surrogate values that have little impact on patient (or clinician) well-being. The sad reality is that those with the power to reform our system, the executives who profit from it and the politicians tasked with regulating it, have little incentive to enact the necessary changes. It falls to those of us who trudge on, waist-deep in the rising waters of our dysfunctional health care system, to join with our suffering patients in collective action to restore the patient and the practitioner to the heart of medicine.
Alexander Raines is an internal medicine-pediatrics physician.
Image credit: Shutterstock.com