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Shame, Guilt, Hypocrisy, and the Burnout Cop Out

2021; Elsevier BV; Volume: 80; Issue: 2 Linguagem: Inglês

10.1016/j.joms.2021.09.022

1531-5053

Benjamin Hechler,

Medical Education and Admissions

I will never forget sitting in a classroom at 6:00 AM in February 2014 for a mandatory institutional lecture. As the lights dimmed and the Powerpoint presentation began, it became clear that the presentation was about physician burnout, this nebulous topic that we all discuss but struggle to understand. The ensuing 45-minute presentation highlighted the purported causes, signs, and symptoms of burnout. As I looked around the room to find half of the audience staring blankly at the screen and the other half staring at the back of their eyelids, I could not help but notice the irony—more truly the hypocrisy—of a mandated 6:00 AM meeting proclaiming we as clinicians needed to take more time to take care of ourselves. Over the subsequent seven years I have come to realize that we are dealing with a “burnout cop out.” This is not to suggest that burnout does not exist but that contrarily, many deeply personal and emotional problems found in medical professionals as well as physician indignation regarding chronic institutional failures are simply labeled as burnout and to some extent dismissed. In my opinion, most academic medical institutions also track physician success using metrics that are at odds with their supposed culture of burnout awareness. This is also a blatant burnout cop out. When physicians find great joy and intellectual stimulation in their work yet feel utterly hopeless and defeated regarding institutional resources and increasing institutionally driven patient expectations, this is once again labeled as burnout. I will touch upon all of these points. Review of the archives of the Journal of Oral and Maxillofacial Surgery reveals a handful of articles commenting on burnout among oral and maxillofacial surgeons (OMSs). The nebulous nature of this entity and how to actually measure it is evinced by the fact that a recent study concluded, using standardized metrics, that as a group OMSs are not at risk for burnout.1Milder MJ Roser SM Austin TM Abramowicz S Does burnout exist in academic oral and maxillofacial surgery in the united states?.J Oral Maxillofac Surg. 2021; 79: 1602-1610Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The results of this study mirror nearly identically the results of a recent faculty survey at my institution where there was found to be a high sense that work was personally meaningful yet a high degree of hopelessness, exhaustion, irritability, and emotional hardening. Discussion was entertained by some that because work was still found personally meaningful burnout was not likely a primary process at work. The current working definition of burnout is flawed. What is missing from routine metrics of burnout—if we must insist on using that term—is shame. Shapiro et al recently showed that residents who were frequently shamed (defined as banishment, threatening, or name-calling) were significantly more likely to meet standard burnout criteria than those who had experienced few or no shame events.2Shapiro MC Rao SR Dean J Salama AR What a shame: increased rates of OMS resident burnout may be related to the frequency of shamed events during training.J Oral Maxillofac Surg. 2017; 75: 449-457Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar To build upon the role of shame in burnout, however, we must realize that the feeling of shame requires neither simultaneous guilt nor a specific “shame event” to occur. Guilt and shame are emotions that we all have experienced to various degrees, and both are required for normal human functioning. In an overly simplified distillation, guilt can be both a subjective emotion or objective declaration: I can feel guilty for having done something wrong or can be guilty even if I do not feel as if I have wronged another. In contradistinction, shame is truly an emotionally subjective experience: I can feel shame regardless of objective truths, and although others can proclaim I should be ashamed of myself, shame cannot be declared by another. On the extremes of the psychologic spectrum, objective guilt without a sense of shame is present in psychopathy whereas shame without guilt leads toward neurosis. Pessimism, cynicism, and depression can be found in various domains of shame and guilt as a deviation from a desired neutral point of healthy functioning (Fig 1). Criticism of one's performance by academic institutions, if covert, is rampant. Academic physicians are evaluated by institutional metrics of success that often are paradoxical and/or hypocritical with regard to personal well-being, shame, and thus burnout. A subset of examples includes: 1) increasing relative value unit (RVU) goals while tightening operating room schedules, 2) demanding increased clinic throughput per given time unit while simultaneously tracking provider satisfaction metrics, 3) skeletonizing clinic personnel for financial purposes while simultaneously tracking office satisfaction metrics, and 4) tracking the speed at which physicians sign notes and respond to patient queries. The conscientious provider who inherits these unattainable goals is likely to feel increasing shame (“I am not measuring up”) and is likely to become more cynical and pessimistic (“no one cares about me; there's nothing I can do; this is hopeless”). Physicians are increasingly being asked by institutions to provide for patients that which we cannot even provide for ourselves. Technology, under the guise of increased efficiency, has only worsened this phenomenon. Consequently, those of the readership are likely familiar with travesties such as receiving emails introducing refreshing, burnout bashing “Mindful Monday” classes while concurrently having their EMR access flagged for not responding to innumerable and incessant patient queries. Criticism of one's performance by colleagues and patients adds to this sense of shame, particularly in the highly conscientious individual.3Laskin DM Combating Professional Burnout.J Oral Maxillofac Surg. 1984; 42: 348Abstract Full Text PDF Scopus (1) Google Scholar Even if these critiques are overall mild in degree, the damage of their increasing frequency cannot be ignored. As mentioned previously, this critical overload has recently been exacerbated by the development of “helpful” patient tools such as electronic medical record messaging systems (whereby patients have the 24/7 ability to message their provider directly about absolutely any question or concern and, per institutional protocol, expect a response) and some more recent institutional interpretations of governmental policies such as the 21st Century Cures Act421st Century Cures Act, 130 Statq (2016). Pub L No. 114-255. Accessed February 9, 2021. https://www.congress.gov/114/plaws/publ255/PLAW-114publ255.pdfGoogle Scholar (whereby institutions now allow patients immediate access to every single medical detail remotely related to their care, even when there is absolutely no benefit to the patient and only the possibility of confusion). This is yet another travesty of increased patient access and control. The clinician has limited choices when responding to the consequent inflow of questions, concerns, and comments, all of which are self-detrimental to reputation or psychological well-being: 1) acquiesce to this constant flow of requests and complaints and bear the loads personally, 2) off-load the increased flow primarily to auxiliary personnel, or 3) realize the futility of the prior two exercises, refuse to comply, withdraw, and drift further into cynicism. In his last special before quitting touring due to job-related anxiety and personal depression, comedian Bo Burnham comments to his sold out crowd, “I can sit here and pretend that my biggest problems are Pringles cans and burritos; the truth is my biggest problem's you. I want to please you, but I want to stay true to myself. I want to give you the night out that you deserve, but I want to say what I think and not care what you think about it. A part of me loves you; a part of me hates you; a part of me needs you; a part of me fears you. And I don't think that I can handle this right now,” then acknowledging, in perfect harmony with the name of his special, Make Happy, that his entire performance career has been an attempt to give others what he cannot give himself. The final four words of his special are a sincere, “I hope you're happy,” as he walks off stage for the last time.5Burnham B Make Happy. Netflix, Port Chester, New York, USA2016Google Scholar To me, it seems the term “burnout” has been partially hijacked so that medical professionals with exacerbations of underlying psychiatric diagnoses, those disillusioned by institutional frustrations, those with true emotional and depersonalization burnout, and those in yet other various mental and physical states are lumped together, all while the institutional juggernaut is barreling along, developing new methods to improve its own image. We will increasingly find ourselves choosing between acquiescence and staying true to ourselves and our families, with patients purposefully placed in the middle as institutional pawns. It is only a matter of time until more of us decide that we, too, cannot handle this right now.