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Board-certified pediatrician and certified coach Jessie Mahoney discusses her article, “Medicalizing burnout misses the real problem.” She argues that the health care industry’s current approach to physician burnout is failing because it treats a predictable cultural problem like a personal disease. By “medicalizing” wellness with endless surveys, modules, and screenings, institutions are trying to solve the issue using the very system that caused it, which only adds to physicians’ burdens. Jessie asserts that physician unwellness is not a pathology but a natural outcome of a culture built on perfectionism and self-erasure. The true solution, she contends, is not another checklist but deep cultural healing. She calls on institutions to offer meaningful support that actually repletes and empowers physicians—such as coaching, connection, time, and space—so they can lead the change medicine so urgently needs.

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Transcript

Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Jessie Mahoney, MD, pediatrician and certified coach. Today’s KevinMD article is “Medicalizing burnout misses the real problem.” Jessie, welcome back to the show.

Jessie Mahoney: Thanks so much for having me. It’s nice to be here.

Kevin Pho: All right, what’s this latest article about?

Jessie Mahoney: So this article is me sharing a long-time frustration about the way we have been approaching burnout in medicine and the surveys and the measuring and even the approaches, which are really in our medical world. We are really approaching it as a medical diagnosis and coming up with solutions which haven’t worked in the same culture and realm that has caused the burnout itself.

Kevin Pho: So when we have these surveys that ask clinicians about these burnout symptoms, what are they like? What kind of questions are they asking?

Jessie Mahoney: I mean, they’re basically asking how you’re feeling, what your thoughts are about work, what your thoughts are about home, and whether you feel like you have enough time for things. I personally have noticed, I know that many of them are validated surveys, but I get different answers on different days in the same week. We love to measure things in medicine, and I think early on in the sort of exploration of burnout, we really did have to prove that there was a problem. But these days, we know there’s a problem. To me, maybe we should be measuring things like retention. Maybe we should be measuring things by mental health referrals or longevity and fulfillment scores and things like that, which we don’t measure. We literally measure burnout.

And to be fair, that’s sort of what we have surveys and questionnaires to measure. But those surveys aren’t measuring systems improvements. They’re not measuring how long people are staying in their career. They’re not measuring how long people are staying in a particular environment. And so I think burnout is really an expected problem in our current system. It’s a cultural problem. We’ve conditioned behaviors that lead to burnout. And so measuring these things and measuring something that we know is already there, to me, is not solving the problem. It’s actually even part of the problem. I think many of us feel more burnt out when we’re asked to fill out more burnout surveys.

I have actually found, when I’m working with organizations, I like to ask sort of written questions. How are you feeling? And maybe a few checkboxes because people like to measure something. Was this valuable? Did it help, and did it help three months later, six months later, a year later? But not using these traditional, formal surveys because I think we’re burnt out on burnout surveys.

Kevin Pho: There’s a certain irony that you point out that these systems are adding to physicians’ burdens by trying to solve the issue using the very system that caused the issue in the first place.

Jessie Mahoney: Exactly. I think it’s really a predictable outcome. If you have a culture that’s about over-functioning and perfectionism and such, of course you’re going to get burnout. And then wellness, as a former institutional wellness leader, I think that within institutions, it’s also a task. It’s a job, and so much of it is, “Well, what are you doing? And have you met these boxes?” I think a lot of the frameworks are like, “Have you done something in all four categories?” and again, sort of the checkbox solution, which hasn’t worked so far.

Kevin Pho: You’re behind the scenes. When a system collects all this data from these surveys, what exactly happens as the next step behind the scenes?

Jessie Mahoney: Well, they go to the wellness leader and say, “You should solve this problem.” And yet we don’t, I would say, necessarily have the tools or the resources, and the solutions are beyond a single event. They’re beyond a yoga class; they’re beyond community and collegiality. And while these things are helpful, we actually need all of them. What we need is a culture that supports physicians as humans and a culture that supports thinking about sustainability.

I like to think about it as sustainability is the highest bar because we need people to stay in medicine. And sustainable medicine is not low-bar medicine. It’s actually the highest bar, right? Because if you’re providing really high quality of care, that’s going to be sustainable. If you’re providing cost-effective care, that’s going to be sustainable. But that comes from healthy physicians, not burnt-out physicians. So it’s looking at it from a much more global sense.

I think that we have to change the culture if we’re going to solve burnout because that’s where the solutions come from. The culture can’t be that—we’ve talked a lot about self-sacrifice—but it also can’t be that doing more is better and the doctors that do more are better doctors, whatever “better” means. They’re more burnt-out doctors, right? And that doing more and seeing more patients is caring more, or charting while you talk to patients because it’s more efficient is better care. That all leads to burnout.

Kevin Pho: Why is it so difficult for hospitals to change their culture?

Jessie Mahoney: Well, we don’t like change in medicine as a culture, to start. I think there’s fear, and we want to make the right change and the change that works. So there’s fear of making a mistake. My personal thought is also that medicine has become a business, and so how do you take something that was never intended to be a business—medicine—and apply business principles to it? And so, it really has to get at, well, if our mission in health care is to have good health care in 20 years, I think we probably have to look much farther out. How are we going to do that, and what’s required to create a sustainable system? But currently, I think it is very hard for hospitals. I don’t think it’s intentional. I think we’re taught a way to think, and we are so entrenched in that, and we are exhausted and depleted and under-resourced. We don’t have enough resources. And so it’s like, “Well, what’s the minimum we can put here?” And they’re putting a bit on everything.

I think we also put so much emphasis on the regulations and the way that we have to comply with all these things that there’s not enough capacity to do all of the things. And yet, if we really look at root causes, if you have healthy physicians and a healthy culture, we know that other things come from that. Potentially looking at other business models and how they’ve approached things, having healthy spaces to work leads to healthier physicians. Having play and having—I’m thinking about the Googles of the world—they have good food, for example, and sunlight and windows. And these are not things that in health care we have absorbed because culturally we said they weren’t needed. Right? You can be a resident in the hospital, which means you live in it. And yet, in most places that we sleep in hospitals, they are not places where we can actually sleep and restore.

And so until that becomes part of the culture of medicine, I often liken it to professional athletes. They have all these things that are taken care of. And it’s not that we need to be treated like royalty or in a luxurious way, but when you support people who are being asked to do really difficult things well, they can actually perform at a higher level. And so if we want to think about medicine as a business in that way, we should really be flipping the script and changing the culture and the narrative.

Kevin Pho: You mentioned retention rates earlier on. Don’t medical institutions care about that because it costs so much to replace a physician? If you had a group of clinicians leave because of their burnout, wouldn’t that get the attention of a medical institution and force them to change their culture?

Jessie Mahoney: It’s starting to, is what I’ll say. I think that it’s slow, and what I see now is that a lot of the incentivization—if that’s a word—behind a lot of their new focus on wellness is that they’re recognizing that it costs a tremendous amount of money to replace physicians and that when you lose people and you are poorly staffed, your burnout rates actually go up and up and up. And so I think that that is the incentive a bit. A bit ago, the incentive was more around quality of care and cost of care. Now it’s really around being able to retain enough physicians. But again, we ride that fine line. It doesn’t mean that people want to pay physicians more or make it a really pushed job to get them to come. It’s like, how can we do it with the bare minimum of keeping people in medicine?

Before, if physicians left, it was really seen as a personal weakness. These days, I think that was the story that was told for a long time, which is why I think this is the beginning of the story. Because now it’s being seen less as a personal weakness and more like, “Wow, maybe we need to change systems.” But I think we’re just on the cusp of that. And the realization hasn’t been that it’s a systemic problem that people are leaving until more recently. And maybe COVID highlighted that a bit. As physicians, we also judged one another about leaving. And rarely did we say, “Oh, the system needs change.”

Kevin Pho: One of the points that you make in your article is that when physicians leave the work of designing better systems to others, it doesn’t always turn out well. So physicians themselves have to change the culture from within. So talk more about that.

Jessie Mahoney: I think that’s absolutely critical because, one, we’ve left the work of redesigning to people outside of medicine. It hasn’t gone so well. And part of the reason we haven’t been able to do it ourselves is that when we’re not well, we can’t use our smart brains to find the solutions. But when we’re not well, and when we’re steeped in this culture of comparing ourselves to others, judging one another, judging people who leave, feeling shame if it’s not working for us, and literally hiding what’s not going well—because in medicine, the culture is, if you’re struggling, that’s not OK. Really, it’s just as simple as that.

And so we have to begin to treat each other as a valuable commodity and to recognize that if we aren’t all supporting each other in having healthier physicians and a healthier culture—which we have not—that it isn’t going to change. Because we are the only ones who can create that culture. We are still perpetuating the culture of judgment and the culture of self-sacrifice and the culture of martyrdom, and that that is better and seeing more patients is better. It’s beginning to shift, but I strongly believe that the shift has to come from within, and it has to come from healthier physicians.

This is where we haven’t done ourselves a service. We haven’t stood up for one another. The culture to get here was so competitive that we’re sort of steeped in that, and then the external systems have made it more so. We’re compared against each other as to how many patients we see and what our scores are and RVUs and this and that. And then added to that is this culture of scarcity. And so we’re all afraid that we will get fired, there aren’t enough jobs, we’ll be replaced, and all of that feeds the problem.

The work that we do on ourselves to sort of recognize our own value and to recognize how we got here and the ways we’re thinking and the ways we’re treating other people can begin to change. I think it probably is going to have to start with physician leaders. I work with people in training, fellows in particular, and I think we can tell people in training to change, but if their leaders and attendings haven’t changed, it’s not a really fair setup. And so similarly, if you come into a practice or an institution and you’re new, and people who are in leadership roles aren’t understanding this, that’s also going to make it incredibly difficult for you.

And so it has to happen at all levels, and we have to begin supporting one another. We can, and we should. I think there’s such a loud voice now about what’s needed, and yet what I haven’t seen yet still is physicians really dedicating themselves to one another. We think it’s about the profession or about the patients, but we have to take care of each other if things are going to change.

Kevin Pho: We’re talking to Jessie Mahoney, pediatrician and certified coach. Today’s KevinMD article is “Medicalizing burnout misses the real problem.” Jessie, as always, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Jessie Mahoney: My take-home message would be that we have to get creative about solving this, and I think we have to move beyond measuring and our typical wellness programs and really think about wellness as supporting physicians such that we can each individually show up differently. Then we can work together to create change and to focus more on retention and functional systems and looking for the diamonds in the rough: where are programs working, where are systems working, and what can we learn from them? I believe, and this is what I see, when you find those, it’s because the people within them are approaching it differently, creatively, and outside the box.

Kevin Pho: Jessie, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Jessie Mahoney: Thank you.