Physician Unions Won't Fix Burnout
And why there is no single pill for demoralization syndrome
Hope you’re having a good week. Something of a controlled rant here. So pardon any disjointed logic, typos, etc. If you’re stumbling here via the infosphere, be sure to subscribe and get savory thought nuggets like this hot and fresh in your inbox.
This essay, Doctors Aren’t Burned Out From Overwork. We’re Demoralized by Our Health System, in the New York Times is getting lots of play. MedTwitter is just gushing over the coining of healthcare’s latest affliction: demoralization syndrome. At the time of posting this, The Times has it as its most popular piece.
Not sure what demoralization syndrome is? Well, it's ...
..a condition commonly associated with terminal illness that’s characterized by a sense of helplessness and loss of purpose. American physicians are now increasingly suffering from a similar condition, except our demoralization is not a reaction to a medical condition, but rather to the diseased systems for which we work.
I’ll concede that it’s a pretty snappy term. And I can guarantee that you’ll see this in the title of an upcoming Grand Rounds.
The editorial fails to offer even a polite nod to Dr. Wendy Dean, my med school classmate, who originally described the idea of moral injury in JAMA in 2020.
My issue is less with coining new words, but the author’s magical thinking that unionization will right the burnout ship. Sure, we’re exhausted. But walking a picket line won't make us less tired. Or less demoralized. And I can’t imagine what would be more demoralizing than seeing our cardiothoracic surgeon pacing in front of the hospital wearing an ‘On Strike’ sandwich sign.
But it seems I'm in the minority here.
Because when I suggested that unions wouldn't make us happy, the Twitter judiciary railed back falling just short of calling me a scab.
What proof do you have that unions won’t solve healthcare?
Hmmm. Ya got me.
Burnout as a wicked problem
It’s important to recognize that the number of emotions conjured up by ‘burnout’ ‘moral injury’ demoralization syndrome are surpassed only by the problem’s myriad of definitions. In fact, it seems every passing negative emotion experienced by a physician is glommed on as a characteristic of this growing condition. It’s the chronic fatigue syndrome of our generation.
But we need to be careful of fancy words that characterize our issues so simply.
Because burnout is a wicked problem. A wicked problem, as described by Tressie Cottom, is a complex societal challenge, that cuts across multiple institutions and brings together numerous stakeholders with competing interests. Because of this, the more you pull at a wicked problem, the more you create another problem. And wicked problems don’t have simple, editorial solutions.
To illustrate the complexity of factors contributing to demoralization syndrome, we could cherry pick just one: information overload. As doctors we are facing a crisis of inputs. The annual in office physical has morphed into what seems to be real-time patient contact and endless MyChart messages. Patient data is flowing to our phones and watches and dashboards. Beyond patient data, medical information and knowledge is mushrooming.
And this crisis of knowledge (that’s my neologism, sorry) is just one small contributor to the sense of helplessness that many of us experience. There are dozens of other examples.
Physician unions — Not a magic pill for burnout
The reason editorials like the one cited here stir people is because they acknowledge that we have issues. They point to our silent frustration and sense of abandonment by the system.
But civil disobedience by the medical staff won’t make that go away. And conflating the problem of physician exhaustion with the need for labor organization is something that could only fly on the pages of the New York Times.
And for the record, we know that unions won’t magically fix our problems as doctors. A 2020 study in JAMA found that resident unions offered improved vacation and housing stipend benefits, but resident unions were not associated with improved burnout, suicidality, job satisfaction, duty hour violations, mistreatment, educational environment, or salary.
I’ll finish by adding that the only thing that might have made this editorial more perfect would have been to blame demoralization syndrome on the fine people at Epic. But I’m sure that’s coming.
I’d love to hear what you think in the comments. And if you like this it would be great if you could pass it along to someone who might like it.
Photo by nikko macaspac on Unsplash.
While the essay nails it in the title, that it is the health system demoralizing physicians, the writer falls well short of correctly analyzing the root cause and subsequently offering a plausible solution. The system has fallen under the control of profiteering middle-men operating under an economy that is rife with perverse incentives maintaining a steep cost curve. No amount of organizing is going to effectively reverse this trend. What we need are physician leaders working with industry to re-create a system that re-establishes the patient-physician relationship and arms length financial transactions for health care delivery. Mark Cuban gets it. What he is doing for generic drug purchasing can be done on a larger scale for primary and specialty medicine. The capital costs for such an endeavor will be so large that it can only be done in conjunction with one or more of the giants of industry. Some, like Amazon and CVS, are jumping in, but in my humble opinion are going about it from the wrong angle, first of all trying to muscle their way in to a failing third-party payer system that will maintain the status quo at any cost, and second of all trying to do it at national scale from the get go. It needs to start out locally, as healthcare delivery should be a local economy, and proof of concept needs to occur on a local scale. Start out, for instance, in states with no CON laws. Bucky Fuller said it best: "You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete." Let the “healthcare universalists” have at it! I want to create something better, separate but in parallel to their current mess, that will make them obsolete. My final point is my most important: health care at its very core is first a moral enterprise. Let’s keep it that way. There must be at least one industry giant out there who can agree with that!
Sorry for the rambling... too much to say in a short comment. Thanks for reading through, and thank you Bryan for your thoughtful and sensible writing.
I don't think the suggestion was that participating in picket lines and other activities associated with unionizing/organizing were cathartic and would make us feel better and less demoralized. The suggestion was that physicians don't feel like they have as much of a say in the structure of healthcare and maybe we'll feel less demoralized if we had a say. I am also skeptical of the piece, but I think you're critiquing a poor representation of the essay's argument.