The classical perception of physicians, created and entrenched by their profession, is that of unfeeling practitioners who are detached, or should be detached, from the emotional turmoil of their patients, and of the gruelling nature of their work. It has however become clear that this impression is false, and that doctors are human after all. This explains why burnout is increasingly becoming an existential threat to practicing doctors. Jay Orlander and colleagues trace the high risk of burnout in medicine to an unresolvable paradox – that of physicians striving for a standard of perfection that ‘cannot be consistently achieved‘. In their paper titled The morbidity and mortality conference: the delicate nature of learning from error, the authors refer to this high expectation of perfection as a ‘necessary fallibility‘ that is ingrained in clinical practice .
Why do dedicated physicians fall victims of their own profession? The answer is perhaps best illustrated by David Hilfiker in his deeply moving book titled Healing the wounds. A physician looks at his work. Hilfiker highlighted the emotional vulnerability of doctors that is inherent in their relationship with patients when he said ‘all of us who attempt to heal the wounds of others will ourselves be wounded. Hilfiker went on to portray, in graphic terms, the drivers of what he called ‘the brutal emotional facts of the doctor’s life’. Some of these are:
- The impossibly broad range of knowledge necessary for medical practice
- The ever-present uncertainty in diagnosis and treatment
- The ubiquitous possibility of making life-threatening mistakes
- The denial of ‘the complexities and limitations of medicine’
- The ‘expectation of perfection‘ that modern medicine has created and which patients hold them up to
In Hilfiker’s assessment, the emotional burden for the physician is at its high point in the area of human error. He explained that this is because the precision of modern technology has made society to conceive of error as ‘almost unthinkable‘, and physicians are therefore unprepared and unable to cope when they make mistakes. He referred to the misperception of physician perfection as ‘a grand illusion‘ and ‘a game of mirrors that everyone plays’. Arguing that this is why doctors ‘hide their mistakes from patients, from other doctors, even from themselves’, he remarked that ‘unable to admit our mistakes, we physicians are cut off from healing. We cannot ask for forgiveness, and we get none. We are thwarted, stunted; we do not grow‘. To overcome the emotional burden that comes with human error, Hilfiker recommended that ‘physicians need permission to admit errors‘ and ‘to share them with their patients’. He further cautioned physicians against the temptation to ‘either deny the misfortune altogether or blame the patient, the nurse, the laboratory, other physicians, the system, fate – anything to avoid our own guilt‘.
Beside human error, the daily grind of medical practice itself remains a potent trigger for physician burnout, and one doctor who has depicted this most eloquently is Joanna Cannon in her book Breaking and Mending. She described how her dream job as a doctor ‘turned itself into my nemesis‘, and ‘a nightmare so vivid and so brutal‘. She epitomised this by her constant exposure to ‘the misery and the death and dying‘ which she said ‘whittled away at me until there was nothing of that doctor left’. Her burnout manifested as obsessive compulsive symptoms, loss of appetite, and disrupted sleep, but she pointed out that these symptoms of burnout are often invisible to observers. And there lies the double-edged sword of physician burnout – it smoulders away slowly and unobtrusively until it consumes the unwary physician. You may see my review of Cannon’s book in my other blog – The Doctors Bookshelf.
The ultimate culmination of unmitigated burnout is physician suicide, a peril that Molly Kalmoe and colleagues referred to as ‘a growing professional and public health concern‘. Writing in a paper titled Physician suicide: a call to action, they defined burnout as a ‘triad of emotional exhaustion, depersonalization and feelings of inefficacy resulting from chronic work-related stress‘, and they cited research to show that it affects a staggering 74% of medical residents. They also referred to the figure of 300 doctors a year that commit suicide – much higher than the frequency in other fields, and higher in female physicians.
Pointing out the crux of the matter, that doctors hardly ever seek help for their emotional problems, Kalmoe and colleagues explored different avenues to prevent burnout, and its progression to suicide, and they urged health organisations and professional bodies to:
- Raise awareness of the problem
- Change the ‘stoic culture‘ of medicine
- Make ‘physician wellness‘ a priority
- Foster ‘a culture of wellness and support‘
- Fund more research into the problem
- Encourage protective lifestyle habits such as exercise and mindfulness
- Train physicians to recognise the early signs of burnout
We have now completed our exploration of the behavioural foundations of human error. We will start with the clinical foundations of human error from the next blog post -stay tuned.