Is burnout the correct term to use?

The debate about whether to use the term “burnout” stems from the understandable concern that “burnout” puts blame and responsibility on the individual experiencing it, instead of directing responsibility to a systemic/organizational level. Terms that have been used in the media in an attempt to more accurately describe the psychological phenomenon experienced by physicians include “moral injury” and “human rights violations.”

Yes, the systems that continue to perpetuate excess demands on its workers without adequate support and resources must be held accountable, which is why awareness of all these terms is extremely important in order to minimize the shame, isolation and burden one may feel when in the throes of burnout.

For the past seven years, I have given talks on burnout to premed students, med students, attendings and other clinicians, and each talk always starts with me reminding them that burnout is NOT solely their problem and that institutions must take responsibility to improve the occupational environment and well-being of health care workers. However, to move forward and advocate for change at the systemic level, it is imperative that we come to a consensus and unite on a standardized term that characterizes the syndrome.

How are we affected by burnout?

The topic of burnout has been in the media a lot these past few years, especially with the pandemic causing a mass exodus of health care workers leaving their jobs. The term burnout describes the constellation of symptoms someone experiences when the demands of their work negatively impact them psychologically and physically.

Symptoms of burnout include physical and emotional exhaustion, depersonalization, decreased productivity and reduced sense of personal accomplishment. In 2019, the World Health Organization categorized burnout as an occupational health syndrome in the International Disease Classification (ICD-11).

According to the ICD-11 chapter that includes burnout, “burnout refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”

The updated version of burnout compared to the ICD-10 version is important because it points to the workplace as the source of the problem, whereas the previous definition described it as “problems related to life management difficulty.” Therefore, the newer definition does, albeit subtly, provide a step forward in holding workplaces accountable.

In addition to being formally classified as a syndrome, there is also a validated measure widely used in research studies to assess the impact of burnout, called the Maslach Burnout Inventory. No assessment tools exist for the other proposed descriptors.

Some of the top-cited contributors to physician burnout include lack of autonomy, administrative burden, minimal time allotted to spend with patients, electronic medical records and dealing with insurance companies, although there are others as well.

Among the most concerning consequences of physician burnout include higher rates of alcohol and drug abuse and suicide. Many of us have sadly lost colleagues to suicide. Many of us have also contemplated leaving our jobs (or ultimately leaving medicine overall) due to lack of control and feeling powerless over the systemic issues that deplete and drain us.

Is “moral injury” a better fit?

Many physicians identify with the term “moral injury” because it describes the depths of the psychological wounds inflicted when we are trying to fulfill our purpose of treating patients, yet being met with constant constraints and barriers as a result of our broken health care system.

Jonathan Shay, MD, a psychiatrist who treated Vietnam veterans at the U.S. Department of Veteran Affairs Boston Outpatient Clinic, coined the term in the 1990s and defined moral injury as meeting all three of the following criteria based on the narratives of his combat veteran patients and from Homer’s narrative of Achilles in the Iliad:

• A betrayal of what’s right
• by someone who holds legitimate authority (e.g., in the military—a leader)
• in a high-stakes situation.

Dr. Shay defined the violator as the power-holder. Then, enter Drs. Simon G. Talbot and Wendy Dean’s poignant piece, “Physicians aren’t burning out. They’re suffering from moral injury,” which points out the systemic issues that lead to moral injury of physicians (the inability to provide high quality care to patients when up against an increasingly profit-driven, corporatized health care system) and makes several suggestions on how leaders, administrators and patients can help change the system (the need for leaders who recognize that physician well-being is a priority, the need for patients to demand that insurers provide what’s best for their care, etc.).

In physician social media group posts about burnout, many physicians have shared their preference to describe themselves as being morally injured over burned out. Identifying higher-ups and the health care system as the perpetrator provides validation that the original versions of burnout did not. However, since moral injury is not a formal diagnosis nor syndrome, the ability to advocate for resources to address it is quite difficult.

The term ‘human rights violations’ gains traction

In an attempt to move forward in advocacy of physicians in a way that was lacking with the term “moral injury,” the term “human rights violations” gained traction to better capture the abuse medical students and physicians endure in medical training and practice. Certainly, one may argue that human rights violations is a bit of a stretch, especially since we voluntarily pursue this career with awareness of its grueling, cutthroat nature.

But does that make these practices right? Is it really okay for physicians to oftentimes work over 80 to up to over 100 hours per week while sleep-deprived? Have we been complicit in the abuse by making statements such as “we all have to go through it,” or “I had it worse than you in my days of training” or “medicine might not be right for you if you can’t handle it.”

Some might argue that there are many aspects of medical culture that are definite human rights violations such as bullying, discrimination, harassment, lack of safety, inequitable pay and sleep deprivation. But, when it comes to advocacy, will legislatures empathize with us? Will they look past our status and salaries?

Signing the Lorna Breen Act was a major win

A win for physicians and health care workers in the U.S. was the Dr. Lorna Breen Healthcare Provider Protection Act, which President Joe Biden signed into law in March.

According to the Dr. Lorna Breen Foundation, the new law “aims to reduce and prevent suicide, burnout, and mental and behavioral health conditions among healthcare professionals.” Members of the AOA strongly advocated for this law, and when physicians and medical students met with their legislators to discuss it, it was extremely important to describe the struggles and experiences of physicians.

According to Alyssa Cole, DO, who was awarded the AOA’s Bureau of Emerging Leaders scholarship 2021 and advocated for funding to support the law, “One thing we always try to do as physicians is explain difficult concepts in a way that’s easier for patients to understand. It’s similar for the definition of burnout. We need to explain it in a way that other people, other industries and of course legislators can understand so they can better relate to our situation, what we are experiencing and not just why we need support but how to help us, the helpers.”

The new law is a step toward holding organizations accountable and legitimizes prioritizing the mental health of health care workers.

There are numerous reasons, issues, layers and complexities that contribute to physician burnout, and perhaps that’s the reason it’s so hard to find one “catch-all” phrase to accurately convey and describe the phenomenon. However, instead of debating over what term to call it, we must not lose momentum and instead direct that energy toward advocating for change and calling for accountability in order to fix the broken health care system.

Awareness of moral injury and human rights violations was necessary in order for us to recognize that we are not to be shamed for experiencing burnout. Advocacy efforts must be directed at the system to create change and let employers know that a mandatory resiliency training will not suffice.

Although real change has been slow, it’s happening. Let us be aware of the complexities and nuances of the term “burnout,” but more importantly, may we stay focused on the goal to keep raising awareness and advocating (at a systems level) for changes that we all deserve.

Related reading:

Lorna Breen Act signed into law by President Biden

The Lorna Breen Act: Why mental health matters