The moral manifesto

vivianimbriotis | Sept. 15, 2022, 1:59 p.m.

Let me tell you a story. 

We have within us a well of energy. We give from this well when required by our job (and by other commitments but centrally to this story by our job); we give to our patients, our coworkers, our employers, our research projects. We replenish this well by engaging in various forms of self-care; by meditating, by exercising, by sleeping properly. Ideally, we reach a steady state where our well is fairly full, such that we have a certain degree of reserve capacity – if demands increase, we can maintain the increased workload for a while; we are in a state of “resiliency”. However, if these increased demands continue and we don’t take appropriate measures, our well of energy starts to run low, and we begin to exhibit symptoms of the disease state called “burnout”. This is a ‘psychological syndrome’, characterized by three features: overwhelming exhaustion, a detached and cynical attitude, and a sense of one’s impotence and powerlessness.

This concept of clinically-significant ‘burnout’ was advanced in 1970 by Herber Freudenberger, an American psychologist, and has produced both a schema for detecting and preventing burnout before it takes root, and a set of therapeutics for preventing burnout (Arnold-Forster et al. 2022). Centrally, preventing burnout relies on increasing self-care and self-sufficiency. Meditate. Take up jogging. Get a psychologist.

Throughout medical school I have been proffered an endless sea of advice regarding how to prevent catching burnout, how to minimize my risk profile and how to crawl out of the hole if I fall into it. This advice is often contradictory – “don’t get over-invested in patients”, “don’t emotionally remove yourself from your patients”; other times this advice seems almost impossible to follow – “maintain your hobbies during your junior medical year,” presumably while working 110-hour fortnights.

Burnout, like depression or hypertension, is a socially constructed quantity. 

When we are approached with a construct, we ought to ask:

(1)   Is it powerfully explanatory?

(2)   What is the political result of the concept’s broad adoption?

Leaving aside question 1, in a fabulous review paper, Arnold-Forster and colleagues argue that the political result of conceptualizing these problems as an individual pathological state, akin to (if not precisely) a mental illness, is that that “sufferer bears responsibility for falling short of a wellness ideal.” You should have meditated. You should have jogged. You should have been more – or maybe less – invested in your patients.

And in a fantastic interview with Arnold-Forster and a colleage, Sam Charland, on the medical history podcast Bedside Rounds (you should listen to every episode, yes you), compare and contrast with with an older construct – workforce morale.

As for the explanatory power of burnout...I have no idea how congruent an explanation for behavior 'burnout' as opposed to competing constructs of 'morale' and 'moral injury' are, but certainly external/environmental factors are better predictors of physician distress than internal/individual ones. And of course, any of these analyses will be confounded all to hell.

And let us never forget that many definitions in health are value judgements, where science and mathematics are no help to us.

 So let me tell you a story. 

As a workforce, we have a shared well of energy. We share it because we lean on one another, because we subtly communicate and propagate our emotional states between ourselves. The conditions around us can sap our collective morale, or they can add to it. Events that occur to individuals have some influence, but largely they cancel out in the great stochastic dance of our collective emotional valence.

To improve our morale, we must change our systems.