The messages that sanctify a culture of physician burnout

I realize today that shame, and the stigma about needing help if you’re a care provider, profoundly affected my career path and even my sense of identity. When I was overwhelmed, exhausted, stressed, and scared, did I reach out for help? No, I kept going until I hit a wall, burned out, and left clinical practice. After leaving, did I talk publicly about the chaotic conditions and broken system that led to my burnout? No, I blamed myself and kept quiet for a decade and a half.

When invited to speak on clinician burnout at a recent conference, I decided to focus on the stigma that kept me from seeking help. Upon reflection, I saw that at its core was a mostly unspoken dictum that care providers cannot be fallible and cannot have human needs — as if the only way to help the vulnerable is to be completely invulnerable oneself. I wanted to see how clinicians in practice today view this stigma.

During the session I asked participants — who were physicians, nurse practitioners, psychologists, and students — to write out some of the messages they learned about self-care, being human, and being vulnerable during training or on the job. They submitted their entries on index cards, and volunteers shared their examples in real-time. Here’s what they had to say.

You do not have normal human needs.

“’Real’ ER doctors don’t need to eat or pee during and 8-hour shift. It’s a sign of weakness.”
“Direct quote from an attending: ‘Don’t be a pussy.’”
“Bad situations or outcomes should not have any lasting effect on you.”
“Sleep is for the weak. Sleep when you die.”
“When I was a medical student on urology, the resident was mocked in rounds for needing IV fluids after a bad stomach virus. The resident was only allowed time to get fluids and then had to get back to work.”
“Don’t call in sick. The ER is the best place for you. If you are sick enough, the attending will take care of you. If not, then you can pull your weight as scheduled.”
“Lie about your work hours (unspoken expectation for residents).”

Never display vulnerability.

“What! You hugged your patient?”
“When an unexpected tragedy occurs, BUCK UP. It’s never OK to cry in front of patients.”
“As for vulnerability — this seems to be something that remains shunned. You cannot be weak as a physician.”
“I saw staff manage several critical patients without any appearance of grief or emotional processing.”

It’s OK to humiliate you in front of others.

“In residency, the attending would question us until we were flustered or would cry.”
“A psychiatrist said in a group meeting, ‘Nurses should be seen, not heard.’”
“You should be reading and rereading Harrison’s every day, anticipate patients who will be seen that day, and read those sections ahead of time. (Said with a completely straight face).”

You are a machine.

“Even on days ‘off,’ it is expected that we will respond to emails and pages.”
“We would quiz each other on obscure facts rather than asking about the weekend, hobbies, family, etc.”
“Getting insulted, spit at, and threatened by patients and not seeing any consequences.”
“Patients in the ED can be incredibly rude, and we are expected to smile and appease. I’ve gone from holding a screaming mom after her 6-month old died to another room 5 minutes later to get yelled at for the wait to be seen for a sore throat. It’s soul-crushing.”
“Reverence is given to the physician who sees more patients, works longer hours, and spends more time with patients.”

We need more work out of you, and no complaining.

“I feel invisible, always afraid to ask questions because leadership does not appreciate those with strong views. My voice has been silenced.”
“Just try to double book 2 or 3 more patients per day to raise your RVUs for the clinic. That shouldn’t be hard.”
“You could have the resources you need to practice if you would see more patients.”
“When all the providers’ schedules are full, and a patient walks in expecting an appointment, we are expected to see that patient, which takes time away from our families, for no increased compensation or appreciation. That may happen several times a day.”
“Don’t ‘dump’ your work on others. Stay until the work is done.”

And this note from a participant, which sums up so much in so few words, “Why do physicians have the unshakeable belief that they are not like other people?”

Is it any wonder that physicians and other clinicians are burned out? These messages sanctify a culture where clinicians are expected to be superhuman, robots, and/or machines — and where broken systems, overwhelming clerical burden, and frustrating policies are tolerated.