Joshua Franklin // When we become discouraged we want some medicine. When we are in good spirits we do not need any medicine. You should not mistake medicine for food. Sometimes medicine is necessary, but it should not become our food. (Suzuki, 65)
The sun was setting on a warm spring evening a few years ago as I walked home from a day in the hospital on my internal medicine rotation. I was passing by a small park in my neighborhood, when I saw a classmate. “What are you doing this weekend?” she asked. I told her I was going to a concert at a local bar. “That’s great!” she replied, “It’s so important to take care of yourself!”
I was puzzled by her turn of phrase. I don’t typically think of an evening of local beers swaying to the echoes of indie rock from my high school days as self-care. Self-care: I began to notice this more and more frequently, a catch-all designation for creative and artistic activities that sounded like praise but felt more like condescension. Meditating, reading a novel, writing a poem: all of these became transformed into interchangeable forms of coping. I had come to medical school thinking that the hard work and innovative technology of contemporary biomedicine—in short, medical care—existed so that we might collectively live more creative and beauty-filled lives. But it was turning out that the opposite was the case—literature, poetry, music, and film; all of these are forms of care that might enable us to return to the work of medicine.
The well-being of health professionals is the subject of increasing concern, addressed by a wide range of projects aimed at measuring and intervening upon burnout. As articulated by psychologists in the 1970s and 1980s, burnout is a phenomenon related to occupational stress – in a foundational paper that has since been cited thousands of times, burnout is defined by emotional exhaustion, depersonalization or negative attitudes towards one’s patients or clients, and negative self-evaluation (Maslach and Jackson 1981). And yet while numerous more recent authors describe burnout as a growing epidemic, there is little consensus on exactly what burnout is or how to mobilize against it. As Thomas Schwenk and Katherine Gold wrote recently in an editorial accompanying several large burnout studies in a recent issue of JAMA, “The term burnout has taken on meaning far beyond what is understood about it as an actual diagnosis or even a syndrome. The medical profession has taken a self-reported complaint of unhappiness and dissatisfaction and turned it into a call for action on what is claimed to be a national epidemic that purportedly affects half to two-thirds of practicing physicians” (1109).
As the keyword for such a call for action, burnout ties together a set of stories that the medical community has come to tell about itself. We are told that burnout is a hidden epidemic, that speaking about it has been repressed, but now we must speak about it. From the beginning of our medical training, we are induced to produce reports of burnout and wellness. We are constantly made to discover its presence at every level of our lives, in the crevices of everyday life, in loud dive bars and big old paintings. This pattern should feel familiar to readers of Foucault. In his seminal work on sexuality, he argued against what he called the repressive hypothesis. It wasn’t that society had come to finally allow previously forbidden talk about sexuality, he claimed, but rather that it had experienced a proliferation of new ways of apprehending and articulating sexuality. And, crucially, along with this new language came new obligations of accounting for oneself in relation to normative standards of behavior.
I was once in attendance at a lecture about empathy to an audience of mostly social science students. The lecturer was describing physician burnout, and, knowing I was a medical student, pointed to me in the back of the room and said, “When Josh first got here, he was full of empathy! Then, during his second year, it dropped a bit. And then, when he started his clerkships, it went way down!” She traced a line graph with her hand, which shot to the floor as she described my inevitable tumble down the empathy scale. While this may indeed reflect the average across medical students in studies, I was struck by how easily it became a personal narrative, inflexibly defining my fate. I met the students’ gaze, my presumptive callousness revealed, and I felt trapped in this trajectory, whether it applied to me in part or not at all. Here—in formal pedagogy as well as seemingly insignificant, informal interactions—we learn to narrate our lives using the language of burnout. We are told we are learning how to be aware of burnout or how to prevent burnout, but I think what we are learning is how to be burnt out.
I should be clear that I am not suggesting that burnout is not real. It points to crucial problems that could be seen in different ways, in structural terms (as an effect of commodification in healthcare) or in psychiatric terms (as an entity related to depression). But we could also see it as a particular cultural repertoire for coming to know ourselves and relating to others, and thereby ask what the alternatives might be. Far from abandoning wellness efforts, I agree with those who focus on finding meaning in medicine. But like the negative experiences gathered under the term burnout, these positive experiences must also be cultivated through collective, creative activity.
The term burnout, in its contemporary usage, is often credited to Graham Greene’s 1960 novel, A Burnt-Out Case. But despite what is often implied when the novel is invoked, the principal subject of burnout in the novel is not the physician, Doctor Colin, but Querry, the famous architect who abandons his work to join him in caring for lepers. Perhaps the lesson is that we do not need a medicalized approach to burnout so much as a renewed engagement with these stories, and a new vocabulary for learning how to become healers.
Foucault, Michel. 1990. The History of Sexuality: Volume 1, An Introduction. New York: Random House.
Graham, Greene. 1960. A Burnt-Out Case. New York: Penguin.
Maslach, Christina and Susan E. Jackson. 1981. “The measurement of experienced burnout.” Journal of Occupational Behavior, 2:99-113.
Schwenk TL, Gold KJ. 2018. “Physician Burnout—A Serious Symptom, But of What?” JAMA, 320(11):1109–1110. doi:10.1001/jama.2018.11703
Suzuki, Shunryu. 2011. Zen Mind, Beginner’s Mind: Informal Talks on Zen Meditation and Practice. Boston, MA: Shambala.