FHC #73: The ‘rules of healthcare’ that cause burnout

Dr. Jonathan Fisher was practically born into medicine. All six of his siblings became doctors, following in their father’s professional footsteps. Jonathan, himself, became a Harvard-trained cardiologist, working in some of the nation’s leading medical institutions.

But, in the process of making his family proud, he was becoming anxious, depressed and burned out. He was losing an important part of himself. To make matters worse, when Jonathan finally sought the help of a therapist, he experienced profound shame and felt like a failure.

Nowadays, in addition to being a practicing physician, Jonathan is an advocate. He has devoted much of his career to solving clinician burnout. He is a mindfulness and resiliency expert who runs the Ending Clinician Burnout Global Community and co-hosts the annual summit of same name.

In this interview, hosts Jeremy Corr and Dr. Robert Pearl ask Dr. Fisher about the rules of American medicine that must be broken in order to free clinicians from the shame, anger, frustration and dissatisfaction that cause rampant burnout.

Interview Highlights

On learning the ‘unwritten rules’ of medicine

“I remember my surgery rotation in third year. We had a very well respected general surgeon, resident and a fellow, and I felt like I was in the military, which was a very bizarre thing … I found myself having to walk quite erect, almost like a group of ducklings following this senior surgical resident. [We had] to speak in exactly the way that he spoke, to present in a way that was expected. This was the first time I remember this jarring sense that there were certain rules that were established, rules of behavior if we were to fit in and to excel.”

On seeking professional help for the first time

“I was a resident at the Brigham and I called [the therapist’s office] and I tried not to over-identify myself. And when I first went, I wore a coat so that I could cover part of my neck, and I wore a hat so that nobody in the neighborhood, other residents, would know that I was going to see a therapist. There was a lot of secrecy and there was a lot of shame that was there. I knew very little about the impacts of shame, which really literally means to cover up. That’s the origin of the word. There was so much covering up that I was doing that, eventually, I was unable to feel positive feelings.”

On burnout vs. depression

“There’s an overlap between burnout and depression, but one is a workplace phenomenon, often driven by a certain set of known factors that Tait Shanafelt and others have described beautifully, whereas depression is more of a psychological diagnosis. What I find interesting is … there are overlaps there with the clinical spectrum of depression as well as anxiety … If you look at Medscape’s poll from last year … 70 to 80% of all doctors across 29 sub-specialties reported depression at some point in the last few years.”

On ‘the healthcare system’ and its role in burnout

“People say, ‘Well, you have to change the system.’ I point out that a system is nothing more than a collection of individuals. If our individuals don’t have the presence of mind and the ability to impact change and influence the thoughts, feelings, and actions of other people, then we won’t have a generation of leaders who can make the changes that people so desperately want.”

On the role of clinicians in ending burnout

“I think part of the problem we’re facing in healthcare is that we’re all siloed. We may be siloed in our own institution thinking that we’re doing it best. We may be siloed in our own specialty thinking that we’re better than others. And we know the jokes that the orthopedists tell about the internists and the cardiologists tell about the neurologists, and it’s funny. At the same time, these silos are what are going to keep us from healing our healthcare system. All of these divides need to be bridged. We need to begin the bridging. And so, that’s really the motivation for my work.”

On the problem with ‘moral injury’

“If we use a narrow term like moral injury, it’s a focus on one person, which is the healthcare provider who is injured. I would say that there’s a connotation there, that there is an injurer. Once we have that connotation, there are elements of blame, of blaming the system. I’ve watched this for 10 years. Well-meaning doctors who have no recourse, spend hours of their time talking about us versus them, us versus the system … I think the popularity [of the term] comes from a sense of hopelessness and, frankly, bitterness, which oftentimes is appropriate, but after a while becomes dysfunctional.”

READ: Full transcript with Jonathan Fisher

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Dr. Robert Pearl is the author of a book about medicine’s invisible yet highly influential physician culture. Check out “Uncaring: How Physician Culture Is Killing Doctors & Patients.” All profits from the book go to Doctors Without Borders.

Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify, Stitcher or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn.

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