Conversations on burnout are happening in every corner of our professional discourse. Mayo Clinic has released a physician burnout index and the American Medical Association has a program aimed at preventing burnout. It is a topic of interest on social media sites like Doximity, NEJM Catalyst, and LinkedIn. In response to burnout, the pursuit of non-clinical activities has risen, and more and more medical students are deciding to completely forego a career in clinical medicine. Many established physicians are looking to “get out” of medicine through financial austerity and eventual early retirement.
How did the profession of medicine go from burnout-proof to burnout-prone? Isn’t it a bit sad that more and more physicians are being urged to aggressively save their hard-earned money so they can one day buy a one-way ticket out of the profession?
We frequently hear about excessive patient loads, unsatisfying compensation models, administrative burden, over-regulation, etc. These are problems that must be tackled. But first, perhaps we should put our profession “on the couch” and explore some of the more proximal causes of burnout. We would argue that burnout at its barest form is a lack of motivation; therefore, to prevent burnout, physicians must understand what motivates them (and what doesn’t). Here, we propose a motivation-centered framework to explain and address some of the root causes of physician burnout.
Motivation comes from motivators, which are often categorized as extrinsic or intrinsic. Let’s discuss three extrinsic motivators first: emotion, economics, and inertia. Many physicians enjoy sufficient levels of emotional motivation. Simply caring for patients — watching them improve, helping them through difficulty, hearing their stories — is itself a powerful emotional motivator. Unfortunately, many physicians do not enjoy sufficient levels of economic and inertia-based motivation. Economically, even with a physician shortage, many of us are doing more work for less money. Fewer and fewer physicians are working for equity, but rather are on a salary or a fee-for-service productivity formula. In the meantime, we have seen administrative costs increase in steady fashion.
Inertia, or perceived barrier to change, is typically an extrinsic de-motivator, but if the inertia is good inertia — i.e. if the practice or organization is humming along — inertia can work as a motivator. Since many physicians now work in large and clunky bureaucracies that are woefully unable to act in nimble fashion, inertia in the current landscape tends to reduce motivation rather than increase it. Even physicians in smaller practices feel the negative effects of inertia — not from internal bureaucracy, but rather from external bureaucracy forced on them by governmental rules and regulations.
The extrinsic motivators are not easy for any one physician to change. Improving the extrinsic motivators will take collective action. To start, we suggest that physicians rally around the concept of the Fourth Aim of healthcare transformation, which is improvement of the clinician experience. [The “Triple Aim” or other three aims are cost reduction, improving population health, and improving the patient experience.] The Fourth Aim can be pursued at local, regional, or national levels.
The intrinsic motivators are play, potential, and purpose. Having a professional play space is sorely lacking for many physicians. Younger physicians may feel this deficit the most, as they are more likely to have had a multi-disciplinary educational experience and are accustomed to working in teams rather than as individuals. Professional play is not a way to waste time or not work. On the contrary, it is a form of work, albeit one that is less structured and perhaps even not goal-oriented. It may be something as simple as tinkering with the EMR or watching surgical videos on YouTube. Our brains enjoy play and some would argue that the brain at play is in the best position to learn and invent.
Unfortunately, our economic motivators are often at odds with play. Many physicians are on productivity formulas that dis-incentivize non-billable activities such as writing or inventing. Even academic physicians may find themselves more tied to productivity formulas than they would like. As such, play-related activities are usually done on the side and are not compensated. “Side hustles” may work to a point, but even the most energetic of physicians only has so much margin in his or her life, and only so much income can be sacrificed for uncompensated professional activity. We suggest that organizations step up and build play into the workweek (and paycheck) of motivated physicians. Programs like NHS England’s Clinician Entrepreneurship Programme can serve as models.
The remaining intrinsic motivators — potential and purpose — are intertwined. Many burned out physicians complain of being on a “hamster wheel” that leads to nowhere. In other words, they see little potential beyond day-to-day drudgery in their professional lives. Of course, what each of us sees as potential will vary, but the common thread is that we need potential in order to remain motivated. For some physicians, working toward the apex of clinical care, e.g. ‘doing the big cases’ or ‘taking care of the sickest patients’, is a way to maximize professional potential. For others, potential may be seen as getting involved in administration or health policy. Other physicians enjoy serving the underserved. Wherever the potential may lie, when a physician finds a space where he or she sees potential, he or she will also find purpose – a motivation that transcends the inevitable day-to-day challenges that accompany clinical practice.
In summary, a first step to reducing or avoiding burnout is for a physician to seek the intrinsic motivators of play, potential, and purpose. This can be done by any physician at any time. The second step is to focus on the Fourth Aim of healthcare, which is improvement of the clinician experience. Physicians are already pushing for structural changes that address the extrinsic motivators of emotions, economics, and inertia, and this trend will continue. More and more, change within organizations will be (and should be) evaluated based not only on patient impact, but on clinician impact as well. Physicians who take a motivation-centered approach to burnout reduction will not only be happier at work, but will also position themselves to effect meaningful changes for their peers.
Adam Kadlec, MD, is a urologist at Aurora Health Care in Milwaukee, Wis. He has an interest in healthcare innovation and leadership.
Niraj Nijhawan, MD, is an anesthesiologist at Aurora Sinai Medical Center in Milwaukee, Wis. He is the author of Modern Medicine is Killing You: Start your healthcare revolution now! and is the founder of Life Ecology Organization (leoprogram.com).
