Physicians have the opportunity to shift the systems of health care, as well as the culture of medicine, to help fight back against burnout, according to a presentation at the Ending Physician Burnout Global Summit.

Robert Pearl, MD, said it is easy to see how factors such as insufficient reimbursement and bureaucratic tasks can lead to burnout, but the culture of medicine is just as much to blame for poor mental health among physicians.

Image of burnout
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“We understand that what gives doctors joy and fulfillment is the relationship with their patients and the gratitude they receive, and that has increasingly eroded as the systemic problems have grown,” he said. “Burnout is becoming not just an acute problem but a chronic disease that will not only be here for this generation of physicians — if we don’t do something to change not just the system of health care but also the culture — but will get passed on to the next generation and the generation after that.”

Pearl said physicians need to consider their own role in the culture of medicine, as well as how they can change the systems that govern their profession.

Changing the culture in medicine has always been an issue, in part due to the nature of physician training and how that culture is instilled over the course of a career.

“It’s the norms that we learned in medical school and residency that we carry with us our entire career,” he said. “You don’t learn it in the lecture halls or in textbooks. You learn it by watching the people senior to you, how they behave, the stories they tell, and the language they use. By definition, it’s always 20 years out of date because of how it is transmitted.”

Pearl told the story of Ignaz Semmelweis, an Austrian physician whose suggestion to change aprons and wash hands between patients in order to reduce mortality rates in pregnancy predated Louis Pasteur by several decades. Although these techniques helped reduce mortality by 90% in his hospital, his ideas were rejected simply because of doctors’ perceptions of themselves.

“They couldn’t see physicians as carriers of disease. [They] were healers,” he said. “It was leather aprons as signs of experience. The more blood, the more pus, the more guts, the higher you are in the hierarchy. That is a cultural phenomenon.”

The culture of medicine is not all bad, as was evident during the COVID-19 pandemic, Pearl said, when physicians willingly put themselves at risk to treat sick patients.

“They would don garbage bags when they didn’t have gowns and used salad lids when they didn’t have masks,” he said. “They passed tubes through the mouth to the lungs knowing that every time the tube went through the patient’s vocal cords, the patient would cough, spewing the virus into their faces. They did it anyway. This is the heroic side of that culture.”

However, Pearl said the lasting impacts from the pandemic on physicians’ mental health is unlikely to surface until long after the trauma has passed, and he expects the darker side of the culture — which includes repression, denial, and unwillingness to talk about one’s challenges — to reveal itself as time goes along.

“We tell people, ‘Deny your pain. Work through it,’” he said. “The last thing you would ever do is tell people you have a psychological problem and had to get care or had to leave for an hour to see a therapist to talk about the emotions you were experiencing.”

Once the world emerges from the pandemic, Pearl said physicians have an opportunity to lead the way in transforming American medicine and the culture surrounding it. That begins with confronting the ways they add harm to patients, colleagues, and themselves, he said.

“We have to commit to change. We have to connect. We have to coordinate with individuals,” he said. “Through that process, I think we can improve not just the system of medicine, but also the culture, the health of our patients, the health of ourselves and restore the mission and purpose that led us into medicine in the first place.”