I am an avid medical blogger. Without a doubt, the most common theme I’ve encountered during the past several years is embodied in the following op-ed: “We must help physicians at the brink of burnout, depression, and high stress,” followed by: “Health care has crossed into a realm of moral injury and systemic collapse.”
I tackled the second essay first. I wrote a no-holds-barred response to a physician posting anonymously. He seemed to be deflated (defeated?) over the realization that our health care profession and system are collapsing.
The physician asked: “What if the ongoing hemorrhaging that is happening in hospitals and clinics across the country doesn’t stop? What if there is no one left to stop the bleeding because we all have left the building, literally or figuratively?” I replied emphatically: “Get out of the spiral deathtrap now, while you can, relatively emotionally intact (I presume) before you become a statistic — either by suicide (God forbid) or one of the 500,000+ health care workers who have left medicine since the beginning of the pandemic.”
My advice notwithstanding, I bet when the “hemorrhaging” stops, some physicians will still be in the building. We are a highly resilient group, extremely dedicated, sometimes unfazed by the broken health care system. Some of us specialize in areas that have minimal interaction with the system’s broken parts.
However, hospitalists, intensivists, ER docs, and PCPs are on the front line of care; their well-being will always be in question. I suggested that the aforementioned physician find a job with a better work-life balance, even if it means subjugating his passion for medicine for a 9-to-5 job. After all, medicine is just a job — nothing more — run by the suits at the expense of doctors. Maybe the physician should seek employment in industry, e.g., pharma, health insurance or government. I closed my remarks by encouraging this anonymous physician to speak out against his employer and attach his name to his opinions. The fear of retaliation should not silence good doctors.
I discussed my blogging activities with my daughter, a newly minted family medicine physician. She thought I was wasting my time, because she believed physicians create their own hardships; their problems are self-imposed, she told me. Nevertheless, I responded to the authors of the other op-ed. I wrote that our choices of a career in medicine are virtually unlimited, and there is no reason to stay in a job that is intolerable. Leave before burnout and other forms of emotional exhaustion set in, I recommended. Create a new reality rather than try and change the existing one.
My comments have deep roots in psychological experiments I read about in college. The first experiments were conducted by the physiologist Walter Cannon in the 1920s. He was the individual who described the fight-or-flight response. Cannon realized that a chain of rapidly occurring reactions inside the body helped to mobilize its resources to deal with threatening circumstances.
The term “fight-or-flight” represents the choices that our ancestors had when faced with danger in their environment. Many physicians facing this situation today, however, neither fight nor flee. They seem to be frozen at work, paralyzed by fear. They accept whatever comes down the pike, whatever the powers-that-be hand to them, like an obedient dog, which brings me to the second series of experiments.
The studies were conducted in the 1960s and 1970s by the psychologist Martin Seligman. He showed that dogs subjected to painful shocks made no attempts to avoid them when given the chance, e.g., by jumping over a barrier. Research on what is now known as “learned helplessness” has shown that when people feel like they have no control over what happens, they tend to simply give up and accept their fate. This maladaptive passivity is highly evident in physicians who feel trapped at work and see no future in practicing medicine. The condition of learned helplessness has become a model for major depression, and it can also explain burnout.
I was fortunate to have trained 40 years ago, when practicing medicine was not dominated by business concerns and electronic medical records and when most physicians worked autonomously and were self-employed. It seems we have crossed a chasm now — health systems employ the majority of physicians — and there is no changing the landscape, no going back. We protest, but because the medical profession is (and has been) engaged in an internecine war, there is no uniting force to change the present-day circumstances encumbering medical practice. We cannot declare force majeure for events that are foreseeable. This is the reality we are stuck with, and it is unlikely to improve.
But all is not hopeless. Here are two things to remember. First, Seligman became curious why some individuals did not feel helpless even when hardened by their natural environment. He eventually focused his research on optimism and positive psychology. The aim of positive psychology is to begin to catalyze a change from a preoccupation with repairing the worst things in life to weathering them through optimistic thinking. There is no reason, Seligman believed, that people can’t learn to be optimistic – an outlook we begin to cultivate by challenging and changing our automatic negative thoughts.
Second, I’d like to remind younger physicians who feel helpless and hopeless that even in my era, although practicing medicine may have been more enjoyable, many of my colleagues and I tried out different jobs to obtain the best fit. I actually spent half my career working in non-clinical positions. There were no chains on us then or now. I considered myself a free agent. I called my own shots. I worked on my own terms. When someone or some force changed those terms to my disliking, I went elsewhere. The guiding principle throughout my career has been to act as a “company of one” – the CEO of my own career. My core competencies report to me, and I report to my board of mentors. That is the only reality that matters.
Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. His forthcoming book is titled Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine.
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