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What if burnout is the wrong word for what doctors are actually going through? Gus W. Krucke argues that calling physicians burned out treats a systemic failure as a personal one, and that physicians are not failing, they are grieving a profession that has changed around them. Using a malpractice case over a reversal drug, he shows how doctors are judged in retrospect for decisions made under pressure in the moment, and how that fear drives a culture of self-protection. He draws a sharp line between resilience, which he says blames the physician, and fortitude, the quality he believes every doctor who finished training already has. Krucke is a board-certified internal medicine and emergency medicine physician and a certified hospice medical director. This episode is based on his article “Physician burnout is not the whole diagnosis,” published on KevinMD. Press play to hear why protecting your judgment, your presence, and your fortitude matters more than any metric, and why burnout was never the whole diagnosis.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Gus W. Krucke. He’s an emergency medicine physician. Today’s KevinMD article is “Physician burnout is not the whole diagnosis.” Gus, welcome to the show.

Gus W. Krucke: Thank you so much. This year I am becoming a PGY-39, and that has included a career of internal medicine, emergency medicine, palliative care, HIV/AIDS care, and most of it has been in the realm of academics and teaching. Now I am at a community program teaching in Georgia.

Kevin Pho: All right. In your article you talk about physician burnout, which is a common topic on KevinMD and this podcast. Why did you decide to write this particular article? And then talk about the article itself for those who didn’t get a chance to read it.

Gus W. Krucke: Well, I think that the conversation I hear in the social media realm, and even in a physician conference room, people having coffee and talking about, quote-unquote, “burnout,” is almost a description of symptoms, that an individual is burned out as if it’s their fault.

And a whole system of medicine has changed over the last several decades, and I think physicians are grieving. It is far more than simply attributing a series of signs and symptoms to physicians. It is a whole system that has created a space where physicians are scrambling to understand it and better decide how their voice is going to project into the future.

So I think that the term burnout is insufficient on a number of different levels.

Kevin Pho: One of the things that you mentioned was that sometimes physicians who say they’re, quote-unquote, “burned out,” sometimes they feel like they’re also being blamed for their own burnout as well. So talk a little bit more about that inference.

Gus W. Krucke: So it is easy in the corporate culture of medicine, separated from the doctrine and speech of professionalism that used to occur within the context of physician professional behavior. We see the symptoms of burnout and frustration, and then get called perhaps disruptive, not a team player, dissatisfied, even cynical, and any number of other unflattering adjectives and sometimes adverbs.

And I think that what we would wish to do better is understand where that is coming from. Certainly we are all responsible for our behavior, and I would never say that anything done as an act of unprofessional behavior should be tolerated. But I think we have to understand where physicians are living and where they are right now, just as we have to do when we sit in front of a patient who is a very real person, and they’re coming with a very long list of problems they’re encountering in life, and we encounter them as professionals with tens of thousands of hours, often, of both training and experience.

Kevin Pho: In your article, you talk about a malpractice case about anticoagulation reversal, and you link that to medicine’s hidden curriculum, and all of that, of course, may contribute to how physicians perceive burnout. So for those who didn’t read your article, just tell us a little bit about that case and what we can learn from it.

Gus W. Krucke: In medicine, something had to happen, in time, to take what is a huge and vastly increasing amount of knowledge and information and wrap it up into the kinds of applications of care that maybe are a little bit more standardized. That has become our recipe book, that which we call protocols.

And in many hospitals or in many clinics today, there are the guidelines, the protocols, the way we encounter patients in a rather standardized way. This has taken out of the mix, in many cases, what makes us different from others who provide care in other areas, and that is formation. Physicians develop through formation, over this long extended training, the kind of judgment that occurs on the edge when there is a clinical circumstance that is atypical.

And in the case of anticoagulation, one individual physician makes a choice to use a drug that is relatively novel and stands outside of a protocol, but could be considered quite appropriate if in the next few moments a patient was going to go to the OR and was going to have urgently a surgical intervention to correct a life-threatening problem.

But the circumstances change later, and then the physician is judged in retrospect based on those protocols and those policies. That stands outside of the realm of professionalism and stands inside of what those who don’t know what they don’t know can possibly comprehend. And sometimes it is easy to persuade a jury that a bad outcome, and by bad I don’t mean that it was incorrect, unprofessional, or that there was any malfeasance of any kind.

Life sucks. Things happen. People die. We cannot save everybody. And in every moment a judgment is made, we cannot expect perfect outcomes in life. And this is the uncertainty that has driven the fear-driven environment of self-protection and risk management, costing us, I don’t know, a lot of money in preventing what are considered to be potential errors and/or legal risks, to assure that we are avoiding the pain of a missed diagnosis, or perhaps the misapplication in that particular case of a drug when the circumstances change later, hours after the original decision is made.

It’s complicated, and I think those who don’t know what they don’t know, and can’t understand what it’s like to hold that responsibility in those moments, have a very difficult time understanding what that feels like in that moment for the person who is empowered to make that very human decision and professional decision at that moment.

Kevin Pho: And you put it very nicely in your article. You say that sometimes medicine is practiced prospectively but judged retrospectively, right? And administrators or non-physicians who sometimes make decisions in medical institutions, if they don’t quite understand that, that is going to put, again, some more pressure, another factor that may contribute to physician burnout.

Gus W. Krucke: Yes, I think that sums up the sense of frustration that can lead to a lot of suffering in the health care environment. Physicians are expected to make the right decision every time, and that is not how a profession works, and it’s not how human beings work either. We have to understand that we enter into this contract and this understanding with our patients, that we come to it not as perfect individuals, nor as computers with obvious answers in any given moment.

And if we are to be constrained in every moment of doubt, how can we even measure the impact on patient care when it is being delivered in a contentious and fearful way?

Kevin Pho: I want to bring up a word that is commonly used in physician burnout conversations, and that word is resilience. And there are a lot of negative connotations to that word, because there are some people who say that if physicians aren’t resilient enough, that just blames the physician themselves, and that’s kind of what we talked about earlier in our conversation today. You introduced another word to contrast with resilience, and that’s the word fortitude, right? So what is the difference between resilience and fortitude, and why do these semantics matter?

Gus W. Krucke: I think that for those of us who interview medical students, or have in the past, students wanting to get into med school, wanting to become physicians, we certainly look for qualities of judgment and character and the ability to endure.

But how much must a human being endure? And who decides what that limit is, and if pushing beyond it is even reasonable? How long can a human being master that particular ask? And that’s where resilience can’t find an adequate metric. That has more to do with tonality, and it’s a judgment, and it’s easy to be outside the arena trying to make a call when you’re in the arena taking all the risk in the world, you’re working your butt off, and then somebody’s going to second-guess you.

I believe that the term resilience gaslights physicians. It’s not even appropriate. And it’s so judgmental and so harmful that it affects the psychology of the whole profession. Fortitude is what we have, what all of us have. If you’ve made it through med school, if you’ve made it through a residency, I don’t care who you are, where you are, you are a kick-butt human being with amazing resilience and something even beyond that, a concept of fortitude which rolls in the dice, a conversation about the morality of the profession.

What is it that makes you, in a moment of insecurity and perhaps full understanding about the facts in front of you, that is exercised in judgment at the bedside? It comes from that moral and ethical foundation that you’re there for a reason. You’re not there to make a buck. You’re there to certainly, hopefully, make a living, but you’ve got a contract, an ethical and moral contract, with the human being in front of you.

And very few people hold that kind of power in their hands on this planet. They think they might, but they don’t. And so we should say to each other and pat each other on the back for the amount of fortitude we have exercised already. And there is a point at which it’s OK to say no, no more of this. No more of this negative conversation. We will not have it anymore.

Kevin Pho: So let’s talk about a path forward for our profession. There’s so much to address, so many avenues to go down. What would be some of your first steps that physicians can take to help with this, quote-unquote, “burnout”?

Gus W. Krucke: I think that I understand now, later in my life, some things I didn’t understand earlier as a young man, as a medical student, and somebody in training.

And ultimately, medicine is a profession of presence, responsibility, and judgment. There’s technology, and it will change. Metrics, they’re going to change. Health systems, they’re going to come and go, and they’re going to change. But again and again, we show up for the patients who will be in front of us, despite the depth and breadth of change and the rapidity of it, as AI becomes an even larger force in the world.

And so we’re talking about something that is going to be difficult to rein in and create a recipe or protocol book that’s going to walk us through all of this. But here’s something that we really know very well. The process of getting into med school, going through that, going through internship and residency, and then into practice, sometimes decades into it, is physician formation, professional judgment, fortitude, presence, and responsibility.

We already have those ingredients. We just have to pivot a little bit, and silence the very loud voices on both the very far left and the very far right who really are just unaware of what they don’t know, and take the reasonable approach of walking in a healthy way through all of this change instead of living in victimhood.

Kevin Pho: We’re talking to Gus W. Krucke. He is an emergency medicine physician. Today’s KevinMD article is “Physician burnout is not the whole diagnosis.” Gus, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Gus W. Krucke: I think what I want to leave with the audience are a couple of things. One is, let’s not confuse metrics with meaning. They’re useful, but very rarely do they speak directly to what’s going on with the patient.

The second thing is, protect your capacity for judgment as a physician. Hold on to fortitude. Make the decisions that you think are right. Live in the promise of service.

The third is, remember that your presence, because of the process of formation and the judgment that you have earned, is more than you realize. People look to you as the doctor. They see you in a way that they see no other human beings on the planet, and they will remember you for what you said long after you will even remember the encounter. That’s what I’ve got for my fellow colleagues.

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

Gus W. Krucke: Thanks, Kevin. I appreciate it.