Professional burnout is widely identified using the Maslach Burnout Inventory, which defines it along psychological lines: emotional exhaustion, a feeling of depersonalization and cynicism, and a low sense of personal accomplishment.
Accordingly, the phenomenon of physician burnout is often framed as a personal problem to be solved by means of self-care. While this approach is undoubtedly helpful, it doesn’t sufficiently address the structural factors that contribute to burnout in the first place: namely, those resulting from the growing commercialization of health care. To that end, the capitalist critique of Karl Marx will be useful and will allow us to understand physician burnout as the latest manifestation of what the communist philosopher called alienation.
The traditional conception of burnout
Popularly understood, physician burnout is a problem that affects the doctor as though it was a psychological disturbance. In his book “Stop Physician Burnout,” physician and executive coach Dr. Dike Drummond argues precisely this. He encourages doctors to utilize stress-reduction exercises like mindfulness and positive thinking, striking a healthy balance between physical, emotional, and spiritual well-being.
Implicit in this approach to physician burnout is the idea that individual-level factors are its primary causes. In a chapter titled “What Causes Burnout?” Dr. Drummond identifies multiple stressors like overworking, clerical work, and inflexibility of schedules that lead to the development of burnout in physicians.
This conception of physician burnout, which we might call the traditional one, doesn’t sufficiently address the underlying structural factors that contribute to it. These factors are related to the fundamental transformation that occurred in medicine around the second half of the 20th century: the commercialization of health care.
Commercialized medicine and its effects
In his book, A Second Opinion: Rescuing America’s Health Care, Dr. Arnold Relman takes the position that the commercialization of health care is contributing to the rising costs and stagnating efficiency of America’s health care system. He argues that the emergence of private insurance companies, entrepreneurial physicians, and privately-owned hospitals has radically transformed the practice of medicine from a profession to a business, resulting in an increase in expenditures and the attendant problems of access and quality that characterize our modern health care system.
In describing the effects of commercial interests and market economics on medicine, Relman documents how factors like reimbursement schemes have direct impacts on how doctors practice.
One particularly well-known and robust example is the rise of high-level diagnoses after the implementation of diagnosis-related, group-based reimbursement systems. Another is the increasing tendency for primary care physicians to spend less time with patients to earn more money and meet hospital quotas.
What these examples illustrate is how structural-level influences, like reimbursement schemes, can affect the individual doctor’s experience, imposing certain restrictions and incentives on them that transform their practice. The rise of these influences, which emerge as a result of capitalist influences, are best understood using the Marxist concept of alienation.
Marx’s concept of alienation
The commercialization of health care presents us with the perfect opportunity for Marxist critique. After all, it was the political theorist Karl Marx who first undertook a description of how capitalism impacted an entire class of workers, factory workers called proletariats. Today, we can use the same ideas to describe how capitalist influences on medicine are affecting doctors.
Marx describes how, in a capitalist system, factory workers become estranged from the product of their labor. Whereas craftsmen feel deeply connected to their creations, which serve as forms of self-expression and testaments to the refinement of their art, factory workers — whose labor becomes increasingly fragmented, repetitive, and depersonalized — no longer feel pride in the fruits of their work. They also become estranged by the activity of their work, losing their sense of authentic engagement with it.
Estranged from both the product and the activity of their occupation, proletariats are denied the chance to identify with their work. This separation from the proletariat’s work and his authentic being is what Marx calls alienation.
Burnout as alienation
Restricted as they are by a growing number of bureaucratic considerations and profit-driven incentives, the doctor’s situation can also be viewed as one of alienation.
In the same way that the proletariat ties the significance of his labor to the value of the product, so too does the physician’s service become objectified by diverse metrics and health outcome measurements.
Though useful, these measures are abused when pursued as ultimate ends rather than a means to perfect the quality.
When a doctor’s motivation shifts from the pursuit of the patient’s well-being — an inherently subjective endeavor — to the fulfillment of objective metrics, he finds himself estranged from the products of his work: his contribution to society is reduced to a number, like a salesman who identifies their work in the amount of revenue they bring in.
Additionally, just as the proletariat’s work comes to lose meaning, so too can doctors become increasingly dissatisfied with how they practice, no longer feeling that their work reflects the goals and attitudes for which they pursued medicine in the first place.
Physician burnout is commonly understood as an individual-level problem that benefits from psychologically-therapeutic approaches. But looking at the way that commercialized medicine has transformed the way doctors practice, it’s clear that there are structural factors that are relevant to the problem.
The Marxist concept of alienation provides us with a framework for understanding burnout as a consequence of commercial regulations imposed on the modern physician. Profit-driven motives, insurance reimbursement schemes, outcome metrics, and other factors have transformed the landscape of medicine and estranged the health care provider from themselves and their method of practice.
The solution that this conception of burnout gives us is clear. Self-care cannot be the only antidote. Doctors are encouraged not only to safeguard their emotional well-being but also to re-establish the original motivations that led them to pursue medicine in the first place, practicing in a manner that reflects their authentic desires. In other words, the solution to physician burnout is physician empowerment: a renewed effort to establish a culture of medicine that is free from commercial interest.
Farid Alsabeh is a medical scribe.
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