“Thou must be like a promontory of the sea, against which, though the waves beat continually, yet it both itself stands, and about it are those swelling waves stilled and quieted.”
– Marcus Aurelius
My reaction to this quote, which begins Osler’s Aequanimitas, has changed over the years. When I first heard it, I was filled with a sense of pride and anticipation. I would be that rock, for my patients, for my family, never wavering, never eroding. Eight years on, as I start my career as a practicing internist, I have come to interpret it as a lovely image, and a lovely fairy tale, but just like the idea that a rock can never erode when exposed to the wind and waves, the idea that a physician can be stalwart against the erosion of death, grief, and the incessant professional demands of modern medicine is pure fantasy.
Unfortunately, there are still physicians in positions of authority who dismiss the notion of burnout. Their exhortations of fellow physicians to “toughen up” belong on the football field, not in serious conversations about burnout.
There is now an extensive literature on physician burnout. It is widely accepted that the phenotypic features of burnout track closely with those of major depressive disorder. Many physicians-in-training will experience the symptoms of burnout: the loss of empathy, the loss of fulfillment in our privileged work, the displacement of these feelings onto vulnerable patients and subordinates.
We have an extensive literature on the maladaptive coping behaviors physicians (and other health care providers) employ to self-treat the symptoms of burnout. These include drug abuse, alcohol abuse, and self-harm including suicide. We also see relative stability in the prevalence of physician burnout and coping behaviors over time, which argues not that the deficiencies lie in the individual trainee but that more pervasive social and environmental influences result in burnout and unhealthy coping.
Thus, if we as a profession are working toward reducing burnout and its harmful and avoidable effects on the physician workforce, the answers lie not in admonishing individual physicians for the sinful behavior of feeling sorry for themselves in spite of their high pay and societal prestige and privilege. Rather it requires the profession take stock of itself, and repair the broken systems of support meant to catch those who fall while doing the work we are blessed to do. Straw men and false equivalence have no place in this discussion, as words have consequences and can cause real harm.
I feel strongly about this point because I have experienced both burnout and major depressive disorder. I can say, at least from personal experience, that the phenomenology of each entity is remarkably similar. I can also say that treatment for one has helped the other immensely, and I suspect it is bi-directional, though this is based on personal experience and anecdote alone. Had I read something during my darkest times that portrayed burnout as a symptom of a coddled, entitled medical professional, I can’t say it would have been helpful.
Conversely, what helped was the support and understanding of my colleagues, formally structured therapy sessions, and a SSRI. I share my story only to illustrate the broader point: Burnout is a recognized, very real clinical entity that shares features of depression, and that a culture of acceptance and support is the starting point to help our colleagues struggling with burnout.
Christopher Vercammen is an internal medicine resident.
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