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    a tired doctor sitting in an operation room

    Why Do We Burn Out New Physicians?

    Being a doctor is a noble calling. Does that mean resident physicians should work thirty-hour shifts and defer marriage and parenthood?

    By Abraham M. Nussbaum

    February 2, 2024
    • Andrew Burke

      Thanks Abraham, for this article. Having turned 50 last week I have now spent more than half my life as a doctor and have been reflecting on similar themes to what you have explored. Last year my father retired as a kidney specialist at the age of 79. He loved his job, worked long hours and had looked after some patients for 40 years - some since their first weeks of life. He was able to float above the bureaucracy somehow and one reason he didn't burn out was because of Mum, the happiness of raising his sons, and also, he has never checked his email once in his life- something the rest of us can't avoid. In Australia we have largely avoided the intrusion of the corporate world into the government health system, and we have universal care which means I can offer free hospital care to whoever needs it regardless of their station in life. In primary care/ general practice however this is rapidly deteriorating as poorer renumeration and work conditions is leading to a seemingly rapid collapse. My great aunty was a Catholic nun and nursing sister her whole adult life in the one hospital. As children we used to visit her in the convent attached to the Mater Hospital in Brisbane. Like previous articles in Plough this article touches on the nature of work in general, how much we let it define us and to what degree we should allow it to dominate our search for meaning.

    Incense at 7 a.m. is as nostril-awakening as any cup of hospital coffee. Even before I breathed it in, I was already alert to what awaited me. Anxiety, burnout, fatigue. Many of the medical students would be in their throes. The patients would be too, but dialed up to a clinical concern. Psychosis, suicidality, depression.

    The patients and the students were in the hospital eight blocks away. I was at the cathedral, which sits on a street famous for its unhoused and unwell people, so many of the congregants were seeking shelter. I was among their number because while I am a bad Catholic, my brother is not. He was waiting when I arrived five minutes into Mass.

    In the pews around us, I caught the eye of several homeless men and women whom I have known as patients. We didn’t shake hands. It’s like the song says, “It’s hard to shake hands, when your hands shake.”

    I saw their minds were, like mine, elsewhere. Our bodies were together, but the congregation felt like “Our Lady of the Internally Preoccupied,” as the priest began his homily.

    He spoke with an accent so many degrees further from my own that I strained to understand him. I consoled myself that as torturous the priest’s words would be, they would be few. Weekday Masses are a quick check-off on the to-do list.

    Expectations? Low.

    The priest gripped the lectern, squinted at his prepared text, looked at us, and put his text away.

    “You find a poor person.”

    The priest’s plain words cut through my mental wanderings.

    “You find one, you see.” He pointed a finger right where I was sitting. “Burnout. I hear people talking about this.” He jabbed his finger forward like lightning.

    “The Gospels, they tell you what to do about burnout. You feel burnout? You find a poor person. Give them $20. You no longer feel burnout. If somehow, you still feel burnout, give $20 to another poor person. You no longer feel burnout. If somehow, you still feel burnout, you give another poor person $100. Then you feel good. Amen.”

    He sat down.

    Although the priest met my expectations for brevity, I disliked the sermon. Bicycling back to the hospital, I thought about how physicians like me prefer more detailed treatment plans. Most of our burnout sermons prescribe seven steps to follow or nine action items to check off so we can ward off the wounds of medical practice and training.

    The training is long: four undergraduate years separating the determined from the interested, four medical school years in which you learn 55,000 new words, and at least three years of residency where you learn the acronyms and slang of the specialty organized around the specific organs of the body that you will spend the rest of your days ministering to. The training is hard: to go from a clueless young person to someone capable of caring for people who have lived far longer, a new physician needs a concentrated dose of intense experiences.

    The internist William Osler, a minister’s son who transferred his faith from the church to the hospital, developed the transformative experience of medical training in the late nineteenth century. Osler famously advised medical students that “the way of life that I preach is a habit to be acquired gradually by long and steady repetition. It is the practice of living for the day only, and for the day’s work, Life in day-tight compartments.” Osler called physicians to work so constantly at doctoring that they would look at no horizon beyond each clinical day. It worked for decades after, but lately, those day-tight compartments have burst. Some surveys have found that more than half of American physicians are burnt out, and ninety percent of physicians discourage young people from following them into medicine.

    Despite the discouragement, young people are applying to medical school in record numbers. Back at the hospital after the priest’s sermon, I found a med student and asked why. As we talked, I told him that I tried to follow Osler’s advice to live in day-tight compartments, but I failed. Osler’s hospital days did add up into habits of being able to fully care for the people I meet as patients only because I began living a life outside the hospital as a parent and spouse during medical school.

    In Aequanimitas, a collection of Osler’s writings that was gifted to every graduating medical student for half a century by Mr. Eli Lilly, Osler advised deferring partnering and parenting during medical training. In its 475 pages, Osler used the word love seventy-five times, but only in relation to knowledge, practice, or medicine itself. Osler never wrote of romance culminating in marriage or dissolving in divorce; spouses and children were insignificant others to a true physician. The word “marriage” appears only twice, in an address entitled “Nurse and Patient” that he delivered at Johns Hopkins in 1897, saying “Marriage is the natural end of the trained nurse. So truly as a young man married is a young man marred, is a woman unmarried, in a certain sense, a woman undone.”

    Osler’s account observed one kind of partnership – a male physician who doctors on after marrying a female nurse who gives up nursing to tend home – and made it the model.

    The medical marriage.

    Osler himself did not marry a nurse, but he did woo a woman who understood that a physician was married to his practice first. Grace Linzee Revere Gross, great granddaughter of Paul Revere, was the widow of Dr. Samuel Gross, who chaired Jefferson Medical College’s surgical department. Grace knew what it took to be a leader in academic medicine and rebuffed Osler’s advances until he published his first textbook. The story goes that Osler proposed with the textbook itself, saying, “There, take the darn thing; now what are you going to do with the man?”

    She must have liked the textbook, for she married the man and, within the year, birthed a son. They named him Paul Revere Osler. Osler bragged that he had bested old Dr. Gross, to whom she never bore a child. But tragedy struck even Osler: Paul died before he was a week old. Two years later, Grace birthed their other child, Edward Revere Osler. Tragedy recurred, but at a delay, as Edward was killed in combat in World War I. Osler suffered the losses a parent most fears.

    And yet, Osler’s counsel to medical students after the death of their first child, in an address called “The Student Life,” remained stoic: “What about the wife and babies, if you have them? Leave them! Heavy as are your responsibilities to those nearest and dearest, they are outweighed by the responsibilities to yourself, to the profession, and to the public.”

    For the next century, this counsel was given to medical students and enshrined in training structures. Teaching hospitals either prohibited or actively discouraged the appointment of married physicians to internships until the 1950s. Teaching faculty encouraged engagement in medical labor over entanglements of the heart. The result was that, for most of the twentieth century, American physicians were more likely to delay marriage and less likely to marry a peer than other professionals.

    a tired doctor sitting in an operation room

    Photograph by Aleksandr Lupin / Alamy Stock Photo.

    Even when mores changed and medical schools realized that most students and trainees would seek companionship, schools sought to contain its effects upon training. When I enrolled in medical school, I was given a pamphlet to share with my summer girlfriend, a guide for what to expect of a medical student. Its counsel could be summarized as: You won’t see your man. He will fight disease on the frontline, while you care for the homefront.

    Or to use a different analogy, home generated distracting noise while the hospital generated an educating signal. The partner’s job was to turn down the domestic noise so that the student could focus on the clinical signal.

    In a way, it worked. Two weeks after I dutifully offered the pamphlet to my then-girlfriend, we broke up. She was young, but already divorced. Her first husband had been a medical student. I was no Osler and she was no Grace, so enough was enough. We both needed a different model for partnering.

    Today, few med students or resident physicians want to hear that they ought to defer their personal lives in favor of the physician lives offered by today’s healthcare systems. And yet the statistics show that med students and resident physicians are delaying marriage and parenting at escalating rates. I told the med student that, in my experience, students and physicians shouldn’t.

    I shared that I stayed on Osler’s sensible path for approximately an hour. During the first break on the first day of med school orientation, I met a bright and beautiful classmate. Her smile called me onto a different path. Every day after, I would scan lecture halls looking for a seat next to her, invite her to study groups, and then to meals at my apartment afterwards. Where I would parrot the school’s counsel that, as Osler advised, it was insensible for med students to date. She took me at my word when I said I was just another classmate.

    When she hosted a Halloween party, I thought her invitation was a courtesy. I declined, because I figured she did not know that on all the nights I was supposed to be memorizing how the median, radial, and ulnar nerves descend from the brachial plexus to innervate the hand, I was thinking of her instead. I said no to the party because an evening being near, but not with, my beautiful crush would be dispiriting. Then our classmate Joe convinced me to attend.

    We don’t need Osler’s noble calling, but some humble vocation in a just system where clinicians can give their lives away to patients.

    I assembled the only costume I could make in fifteen minutes: my middle school woodshop teacher. Flannel shirt. Jeans. Shop apron. And a bloody stump where he had severed the middle digit of his fourth finger on a band saw.

    At the party, she rolled her eyes at my shoddy approximation of a stumped finger, and my jokes about how the fourth, or ring, finger, was innervated by the ulnar nerve, but it started a conversation that never stopped.

    Colleagues counseled us to wait, but I asked for her (intact) hand before the end of our second year of med school.

    During our clinical year, we married over the New Year’s holiday, enlisting grad school friends to serve at the rehearsal dinner, a classmate to sew her dress, and a college friend to make the cake in New York City and then drive it down to Chapel Hill. We had a lunch reception instead of a dinner reception, because that was the best way to stretch med school loan checks to cover a good band and good wine and good food to soak it up.

    It was a great party and a great night after.

    Before we finished writing thank-you notes, Elin was pregnant.

    By the end of our third year, Elin and I would bike together in the dark to prepare for surgical rounds. I felt fearful and tired. Elin felt proper sick. Most mornings, we would stop so Elin could quickly vomit in the bushes and entertain the question: is it really morning sickness if it comes before dawn? By the time the sun was up, we were rounding with the team. Prominent surgeons asked her why she was ruining her career with a child, even as she spent hours dutifully holding necrotic limbs for them to amputate. At nights, we cursed the surgeons while practicing our suturing on scrap beef we begged from the butcher.

    She persevered through the rotation, exhibiting all the commitment you can ask of a future physician. When her hand slipped during a lumbar puncture on a patient, Elin stuck herself with a contaminated needle. She and our unborn son were treated for exposure to syphilis. When Eamon was born, Elin took a year off med school. Without parental leave, we took out more student loans to pay for the new member of our family.

    When Elin returned to med school, we swapped call nights and nursery nights for a decade. For a few years, both of us were working thirty-hour shifts every fourth night. Now, twenty years later, when we still have a room in our house designated as a call room, every day remains a negotiation between hospital and home.

    Those negotiations delayed Elin’s dreams – it would be a decade out of training before she earned a leadership role she deserved earlier – but becoming parents focused our practice. After our son arrived, and continuing after the birth of our two daughters, we were purposeful in the clinic and the hospital in ways we had not been beforehand. We would be out in time to collect our children before daycare closed, before supper, and before bedtime stories. We wanted to be there.

    And for us, there meant the home and the hospital.

    Medicine gives out a lot of ribbons and plaques and awards for meritocrats. We missed out on some of them but were gifted homemade paintings and pots instead. Our achievement has been getting the kids to school on time in the morning, working determinedly during the day so that we can return home, to make dinner while checking their homework or coaching their teams at night. Partnering and parenting while becoming physicians means we give our lives away to home and hospital.

    The experience has been challenging and clarifying. The only way to parent infants is to allow them to transform your life. You trade going out with friends for bedtime stories. You miss peak Kanye and every season of The Wire when you are listening to Raffi and watching Pixar films. We found giving your life away to someone else a harder, but more enduring, burnout cure than the life hacks, mindfulness techniques, or retirement planning the hospital offered as solutions. Parenting still had a kind of magic that makes a transformative experience worthwhile. But a real transformation hurts.

    At a Christmas party soon after the morning Mass, my wife’s colleague told me she was retiring. The retiring physician’s grandfather and father were both doctors in the Oslerian mold who impressed upon her that medicine was a life of service – a noble calling, not a mere job. The retiring physician said that made sense to her only when she thought about medicine as a culture and medical training as an initiation rite, like those for shamans in indigenous cultures. A group designates a subset of their number as healers, then sends them out for an experience so difficult they dissociate. During her training, before duty hours restricted a trainee’s time in the hospital, she worked constantly, often completing a forty-hour work shift every fourth night, caring for the ill even as she grew so exhausted that she hallucinated words and images. She dissociated, the walls and floors of the hospital falling away into a kind of wilderness. It was a full initiation rite, a kind of enchantment.

    Decades later, over eggnog and crudité in the expansive living room of her home, the retiree grew wistful. She missed feeling so alive, but she no longer felt the magic. She suspected that part of why today’s trainees suffer so is because they have never been so alive, never felt the effects of full initiation. “We give them a low-grade constant wounding. It is enough to harm trainees, but they no longer have an experience that summons up the old magic.”

    I sidled away, wondering if that was Stockholm syndrome, the nostalgia of a retiring physician, or the wisest insight.

    Since that retiree trained, hospitals have become healthcare systems, medical schools have become academic health centers, and physicians have become providers of healthcare services. Money is the driver of many of these changes, ultimately at the expense of the patients, but we rarely talk about how all that money has driven medicine’s disenchantment. We lost the old dream of medicine, the one where we thought it was Osler’s noble calling, to the vulgar healthcare industry which transmuted a physician’s sacred duties into mundane chores.

    The retiring physician worked more hours during her training than today’s students and residents, but her hours were differently paced when hospitals admitted fewer ill patients for longer stays. The grinding, repetitive work of contemporary physicians can turn even the most idealistic young people into healthcare robots, from the Czech word robota, meaning “forced labor,” instead of something like shamans. And the med students can see, just a few years away, even healthcare robots being replaced with artificial intelligence-generated clinicians. They need a different vision.

    I realize that is what caught me in the priest’s sermon: a reminder of what an enchanted version of charity would look like. A direct encounter. A sacrificial gift. An emptying of my pockets and a filling of someone else’s. Perhaps it is the only way to manage medicine’s money while recapturing some of the old medical magic, that Verzauberung, over the whole of a physician’s life.

    Elin and I entered two of the least remunerative specialties and have worked in safety-net settings throughout our careers, but we still paid off our student loans last year, a decade before they were set to expire by natural causes. Our mortgage too. Our current goal is funding our children’s college funds, which costs more than our mortgage did, but we still have more money than we ever anticipated. While we still work with the constancy our training taught us, we both know patients who work harder than we do, and for far less of the profit that has replaced the magic of medicine.

    When I talk with my wife about what to do with the money medicine makes and how it is making us, her first impulse is to save it. She was raised in New Hampshire, where the Puritan ethic endures as Yankee thrift. When I ask what to do with medicine’s money beyond saving, Elin feels guilty. Her mother is from Donegal and Elin inherited a guilt rooted in ancient Irish injunctions that your money belongs to the poor. Give the money of medicine away or save it? She, finally, always favors the giveaway. When Elin really thinks about money, she is on the priest’s side, favoring the one-step treatment for burnout: give yourself away for the good of others.

    Last month, I was sitting next to Elin in the cathedral for a midday Sunday Mass. It was the one hundred fiftieth anniversary of the founding of Elin’s hospital by a pioneering group of nuns. The nuns opened a small hospital, before our state was founded, then grew the hospital alongside the state. Like Osler’s resident physicians, they lived in the hospital, but not for a brief training experience. The nuns lived on the top floor of the hospital for their entire career. After doctors had gone home for the day, the nuns would check on the patients and the staff too, ministering to them all. The nuns worked clinically at the bedside and administratively in the boardroom, running the hospital for generations. They worked tirelessly, well outside of any day-tight compartments, their lives fragranced by the smells of incense and coffee.

    The hospital was sold recently to an out-of-state health system known for providing efficient and effective care. They do good work, I hear, but I suspect they don’t do the good works the nuns used to do. The nuns are gone now, having made the return trip back east as their numbers have thinned.

    In the black and white photos from the past, there were dozens and dozens of nuns. Sitting in the pews this time, I counted fewer than a dozen nuns in attendance. I felt their presence and their absence. What medicine needs is some new mixture of incense and coffee which awakens us all to the possibility of caring for the sick who can and cannot pay. We don’t need Osler’s noble calling, but some humble vocation in a just system where clinicians can give their lives away to patients. We’re missing the nuns who live burnout sermons instead of preaching them.

    Contributed By AbrahamNussbaum Abraham M. Nussbaum

    Abraham M. Nussbaum works as a physician in Denver at a hospital for people experiencing mental health crises.

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